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Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 1
Coronary ArteriesCoronary Arteries
Supply arterial blood Supply arterial blood to heart muscleto heart muscle Left coronary artery Left coronary artery
carries about 85% of carries about 85% of blood supply to blood supply to myocardiummyocardium
Right coronary artery Right coronary artery carries remaindercarries remainder
Originate above aortic Originate above aortic valvevalve
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 2
Left Coronary ArteryLeft Coronary Artery
Divides into left anterior Divides into left anterior descending and descending and circumflex arteriescircumflex arteries Left anterior descending Left anterior descending
(LAD) supplies:(LAD) supplies:• Anterior wall of left Anterior wall of left
ventricleventricle
• Interventricular septumInterventricular septum
Circumflex supplies:Circumflex supplies:• Lateral and posterior Lateral and posterior
portions of left ventricleportions of left ventricle
• Part of right ventriclePart of right ventricle
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 3
Coronary ArteriesCoronary Arteries
Right coronary artery Right coronary artery and left anterior and left anterior descending artery descending artery supply:supply: Most of right atrium Most of right atrium
and ventricleand ventricle Inferior aspect of left Inferior aspect of left
ventricleventricle Anastomoses provide Anastomoses provide
collateral circulationcollateral circulation
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 4
Coronary CapillariesCoronary Capillaries
Exchange nutrients and Exchange nutrients and metabolic wastesmetabolic wastes
Merge to form coronary Merge to form coronary veinsveins
Coronary sinus empties Coronary sinus empties into right atriuminto right atrium Major vein draining Major vein draining
myocardiummyocardium
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 5
ECG LeadsECG Leads
Two surface electrodes of opposite polarityTwo surface electrodes of opposite polarity Bipolar leadBipolar lead
• Two electrodes of opposite polarityTwo electrodes of opposite polarity
Unipolar leadUnipolar lead• Single positive electrode and reference pointSingle positive electrode and reference point
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 6
LeadsLeads Bipolar leadsBipolar leads
Limb leads Limb leads I, II, IIII, II, III
Unipolar leadsUnipolar leads Augmented limb leadsAugmented limb leads
• aVR, aVL, and aVFaVR, aVL, and aVF Precordial leadsPrecordial leads
• V1 through V6V1 through V6
Each lead assesses electrical activity from a Each lead assesses electrical activity from a different angledifferent angle
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 7
I, II, III Limb lead Bipolar
aVR, aVL, aVF Limb lead Unipolar
V1-V6 Chest lead Unipolar
Lead ComparisonLead Comparison
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Lead Cardiac Surface Viewed
II, III, aVF Inferior wall
V1, V2 Septum
V3, V4 Anterior wall
V5, V6, I, aVL Lateral wall
Leads and Cardiac SurfacesLeads and Cardiac Surfaces
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 9
Standard Limb LeadsStandard Limb Leads
Record difference in Record difference in electrical potential electrical potential between left arm, between left arm, right arm, and left leg right arm, and left leg electrodeselectrodes
Represent axesRepresent axes
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AxisAxis
Average direction of Average direction of the heart’s electrical the heart’s electrical activityactivity
Triaxial reference Triaxial reference systemsystem
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AxisAxis
Lead I is a lateral Lead I is a lateral (leftward) lead(leftward) lead Assesses electrical Assesses electrical
activity from a activity from a viewpoint defined as 0viewpoint defined as 0°° on a circle divided into on a circle divided into an upper negative 180an upper negative 180°° and a lower positive and a lower positive 180180°°
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 12
AxisAxis
Leads II and III are Leads II and III are inferior leadsinferior leads Assess the heart's Assess the heart's
electrical activity from electrical activity from vantage points of +60vantage points of +60°° and +120and +120°°
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 13
Lead Positive Electrode Negative Electrode
I Left arm Right arm
II Left leg Right arm
III Left leg Left arm
Bipolar Lead PlacementBipolar Lead Placement
Limb lead placementLimb lead placement
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 14
Augmented Limb LeadsAugmented Limb Leads
Same electrodes as limb leadsSame electrodes as limb leads Record difference in electrical potential Record difference in electrical potential
between extremity lead sites and a reference between extremity lead sites and a reference pointpoint Zero electrical potential Zero electrical potential At center of the heart’s electrical fieldAt center of the heart’s electrical field
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 15
Augmented Limb LeadsAugmented Limb Leads
Axis of each lead is Axis of each lead is formed by line from formed by line from electrode site to electrode site to center of the heartcenter of the heart
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 16
Augmented Limb LeadsAugmented Limb Leads
aVR, aVL, and aVF leads intersect at angles aVR, aVL, and aVF leads intersect at angles different from those of the standard limb different from those of the standard limb leadsleads
Produce three other intersecting lines of Produce three other intersecting lines of referencereference With standard limb leads, these leads make up a With standard limb leads, these leads make up a
hexaxial reference systemhexaxial reference system
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Lead aVRLead aVR
Distant recording Distant recording electrodeelectrode
Looks at heart from Looks at heart from right shoulderright shoulder
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Lead aVLLead aVL
Lateral leadLateral lead Records electrical Records electrical
activity from left activity from left shoulder shoulder --3030°°
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 19
Lead aVFLead aVF
Inferior leadInferior lead Records electrical Records electrical
activity from left lower activity from left lower extremityextremity +90+90°°
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 20
Limb LeadsLimb Leads
Leads II, III, aVF Inferior leads
I, aVL Lateral leads
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 21
Modified Lead RecordingModified Lead Recording
Limb lead placement altered to mimic Limb lead placement altered to mimic precordial leads (Vprecordial leads (V11 through V through V66)) Modified chest leadsModified chest leads MCLMCL11 to MCL to MCL66
May help:May help: Distinguish between supraventricular tachycardia Distinguish between supraventricular tachycardia
with aberration and ventricular tachycardiawith aberration and ventricular tachycardia Diagnose bundle branch blocksDiagnose bundle branch blocks
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 22
MCLMCL11
Positive electrode in Positive electrode in VV11 position position 44thth intercostal space, intercostal space,
right of sternumright of sternum Negative electrode Negative electrode
placed anteriorlyplaced anteriorly Below lateral end of Below lateral end of
left clavicleleft clavicle
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 23
MCLMCL66
Positive electrode on Positive electrode on left midaxillary line at left midaxillary line at 55thth intercostal space intercostal space As for lead VAs for lead V66
Negative electrode Negative electrode placed anteriorly, placed anteriorly, below left shoulderbelow left shoulder
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 24
12-Lead ECG Monitoring12-Lead ECG Monitoring
10 electrodes10 electrodes Four limb leads (right arm, right leg, left arm, left Four limb leads (right arm, right leg, left arm, left
leg)leg)• Leads I, II, and III, and aVF, aVL, and aVRLeads I, II, and III, and aVF, aVL, and aVR
Six chest leads Six chest leads • VV11 through V through V66
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 25
12-Lead ECG Monitoring12-Lead ECG Monitoring
Leads view left Leads view left ventricle from ventricle from position of its positive position of its positive electrodeelectrode
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 26
12-Lead ECG Monitoring12-Lead ECG Monitoring
Identifies ST segment and T-wave changesIdentifies ST segment and T-wave changes Myocardial ischemia, injury, and infarctionMyocardial ischemia, injury, and infarction
Identifies VT in wide-complex tachycardiaIdentifies VT in wide-complex tachycardia Determines electrical axisDetermines electrical axis
Presence of fascicular blocksPresence of fascicular blocks Determines presence and location of bundle Determines presence and location of bundle
branch blocksbranch blocks
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 27
Precordial LeadsPrecordial Leads
Six precordial leads are projected through Six precordial leads are projected through anterior chest wall toward backanterior chest wall toward back
Positive leads are placed on chest in Positive leads are placed on chest in reference to thoracic landmarksreference to thoracic landmarks Record electrical activity in transverse or Record electrical activity in transverse or
horizontal planehorizontal plane
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 28
Precordial LeadsPrecordial Leads
VV11 and V and V22: Septal : Septal
leadsleads VV33 and V and V44: Anterior : Anterior
leadsleads VV44 through V through V66: Lateral : Lateral
leadsleads
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 29
12-Lead Electrode Application 12-Lead Electrode Application
...
Locate the jugular notchLocate the jugular notch Palpate for the angle of LouisPalpate for the angle of Louis
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 30
12-Lead Electrode Application12-Lead Electrode Application
Follow the angle of Louis to patient’sFollow the angle of Louis to patient’sright until it articulates with 2right until it articulates with 2ndnd rib rib
Locate the 2Locate the 2ndnd IC space IC space(immediately below 2(immediately below 2ndnd rib) rib)
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 31
12-Lead Electrode Application 12-Lead Electrode Application
VV11 is positioned in the 4 is positioned in the 4thth IC IC
space just right of the sternumspace just right of the sternumFrom the 2From the 2ndnd IC space, the 3 IC space, the 3rdrd and and
44thth IC spaces can be found IC spaces can be found
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 32
12-Lead Electrode Application 12-Lead Electrode Application
Place VPlace V22 electrode in the 4 electrode in the 4thth IC IC
space just left of sternumspace just left of sternumFrom VFrom V11, find the corresponding, find the corresponding
IC space on the left side of the sternumIC space on the left side of the sternum
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 33
12-Lead Electrode Application12-Lead Electrode Application
From VFrom V22 position, locate 5 position, locate 5thth IC space, IC space,
follow to the midclavicular linefollow to the midclavicular linePosition VPosition V44 electrode in 5 electrode in 5thth IC space in IC space in
midclavicular linemidclavicular line
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 34
12-Lead Electrode Application 12-Lead Electrode Application
VV55 is positioned in is positioned in
anterior axillary line, level with Vanterior axillary line, level with V44Position VPosition V33 halfway between V halfway between V22 & V & V44
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 35
12-Lead Electrode Application12-Lead Electrode Application
Position VPosition V66 in the midaxillary line, level with V in the midaxillary line, level with V44
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 36
ST SegmentST Segment
Early phase of Early phase of repolarization of repolarization of ventriclesventricles
Follows QRS complexFollows QRS complex Ends with onset of T Ends with onset of T
wavewave
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ST SegmentST Segment
ST segment “takes ST segment “takes off” from the QRS off” from the QRS complex at J pointcomplex at J point
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 38
ST SegmentST Segment
Position of ST segment is commonly judged Position of ST segment is commonly judged using baseline of PR or TP interval for using baseline of PR or TP interval for referencereference ST segment elevationST segment elevation ST segment depressionST segment depression
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 39
ST SegmentST Segment
Abnormal ST segmentsAbnormal ST segments InfarctionInfarction IschemiaIschemia PericarditisPericarditis After digitalis administrationAfter digitalis administration Other disease statesOther disease states
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T WaveT Wave
Repolarization of Repolarization of ventricular cellsventricular cells
Last part of ventricular Last part of ventricular systolesystole
Above or below isoelectric Above or below isoelectric line line
Usually rounded and Usually rounded and slightly asymmetricalslightly asymmetrical
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T WaveT Wave
Deep, symmetrically inverted T waves may Deep, symmetrically inverted T waves may suggest cardiac ischemiasuggest cardiac ischemia
T wave elevated more than half the height of T wave elevated more than half the height of the QRS complex may indicate: the QRS complex may indicate: Onset of myocardial ischemiaOnset of myocardial ischemia HyperkalemiaHyperkalemia
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Note “Rabbit Ear”Note “Rabbit Ear”
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12-Lead Strategies for12-Lead Strategies forWide-Complex Tachycardias Wide-Complex Tachycardias
The presence of right axis deviation (negative The presence of right axis deviation (negative QRS complex in lead I; positive QRS complex QRS complex in lead I; positive QRS complex in leads II and III) and a negative QRS in leads II and III) and a negative QRS complex in MCLcomplex in MCL11 (V (V11) indicates VT) indicates VT
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 44
Right Axis Deviation and a Right Axis Deviation and a Downward MCLDownward MCL11 Indicates VT Indicates VT
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12-Lead Strategies for12-Lead Strategies forWide-Complex TachycardiasWide-Complex Tachycardias
VT if:VT if: All precordial leads (V leads) are either positive or All precordial leads (V leads) are either positive or
negative negative • Precordial concordancePrecordial concordance
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VT-ConcordanceVT-Concordance
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12-Lead Strategies for12-Lead Strategies forWide-Complex TachycardiasWide-Complex Tachycardias
RS interval >0.10 sec in any V lead RS interval >0.10 sec in any V lead indicates VTindicates VT
Increased ventricular activation timeIncreased ventricular activation time
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Ventricular Conduction DisturbancesVentricular Conduction Disturbances
Bundle branch blocks or hemiblocksBundle branch blocks or hemiblocks Delay electrical transmission below bundle of Delay electrical transmission below bundle of
HisHis
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Bundle Branch Blocks and HemiblocksBundle Branch Blocks and Hemiblocks Common causes of bundle branch blockCommon causes of bundle branch block
Ischemic heart diseaseIschemic heart disease Acute heart failureAcute heart failure Acute myocardial infarctionAcute myocardial infarction HyperkalemiaHyperkalemia TraumaTrauma CardiomyopathyCardiomyopathy Aortic stenosisAortic stenosis InfectionInfection
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Bundle Branch AnatomyBundle Branch Anatomy
Bundle of His divides:Bundle of His divides: Left and right bundle branchesLeft and right bundle branches Right bundle branch continues toward apex and Right bundle branch continues toward apex and
spreads through right ventriclespreads through right ventricle Left bundle branch subdivides into anterior and Left bundle branch subdivides into anterior and
posterior fascicles and spreads through left ventricleposterior fascicles and spreads through left ventricle Electrical impulse conduction through Purkinje Electrical impulse conduction through Purkinje
fibers stimulates ventricular contractionfibers stimulates ventricular contraction
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Bundle Branch AnatomyBundle Branch Anatomy
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Bundle Branch AnatomyBundle Branch Anatomy
Normal conductionNormal conduction Left side of septum is stimulated firstLeft side of septum is stimulated first Electrical impulse traverses septum to stimulate Electrical impulse traverses septum to stimulate
other sideother side Left and right ventricles are then simultaneously Left and right ventricles are then simultaneously
stimulatedstimulated
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Normal Ventricular Activation Normal Ventricular Activation
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Bundle Branch BlockBundle Branch Block——ECGECG
One ventricle depolarizes and contracts One ventricle depolarizes and contracts before the otherbefore the other
Ventricular activation is not simultaneous, Ventricular activation is not simultaneous, therefore QRS complex widenstherefore QRS complex widens Slurred or notched appearanceSlurred or notched appearance
• ““Rabbit ears”Rabbit ears”
QRS complex is QRS complex is >>0.12 sec0.12 sec
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Bundle Branch BlockBundle Branch Block
Criteria for bundle branch blockCriteria for bundle branch block QRS complex QRS complex >>0.12 sec0.12 sec QRS complexes produced by supraventricular QRS complexes produced by supraventricular
activityactivity
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Bundle Branch BlockBundle Branch Block
Leads VLeads V11 and V and V66
MCLMCL11 and MCL and MCL66
Permit differentiation of right and left bundle Permit differentiation of right and left bundle branch blocksbranch blocks
Normal conductionNormal conduction VV11 (MCL (MCL11) is predominantly negative) is predominantly negative
QRS complex is 0.08-0.10 sec QRS complex is 0.08-0.10 sec
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Right Bundle Branch BlockRight Bundle Branch Block
Left bundle branch performs normallyLeft bundle branch performs normally Activates left side of heart before rightActivates left side of heart before right ECG characteristicsECG characteristics
Initial negative deflection (S wave)Initial negative deflection (S wave) RSR-prime patternRSR-prime pattern QRS (or in this case, RSR) duration QRS (or in this case, RSR) duration >>0.12 sec0.12 sec
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Right Bundle Branch Block Right Bundle Branch Block
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Left Bundle Branch BlockLeft Bundle Branch Block
Fibers that fire interventricular septum are Fibers that fire interventricular septum are blocked:blocked: Alters normal septal activationAlters normal septal activation Sends it in opposite directionSends it in opposite direction
ECG characteristicsECG characteristics Initial Q wave in VInitial Q wave in V11 (MCL (MCL11))
R wave in VR wave in V11 (MCL (MCL11))
Deep, wide S wave (QS pattern)Deep, wide S wave (QS pattern) QRS duration QRS duration >>0.12 sec0.12 sec
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Left Bundle Branch Block Left Bundle Branch Block
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Left vs. Right BBBLeft vs. Right BBB
Find J point Find J point Draw line back into Draw line back into
QRS complexQRS complex Fill in triangle Fill in triangle
createdcreated Note direction Note direction
triangle pointstriangle points
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Anterior HemiblockAnterior Hemiblock More common than posterior hemiblockMore common than posterior hemiblock Anterior fascicle of left bundle branch is a longer Anterior fascicle of left bundle branch is a longer
and thinner structureand thinner structure Blood supply primarily from left anterior Blood supply primarily from left anterior
descending (LAD) coronary arterydescending (LAD) coronary artery Anterior hemiblock characterized by left axis Anterior hemiblock characterized by left axis
deviation in patient with supraventricular rhythmdeviation in patient with supraventricular rhythm
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Anterior HemiblockAnterior Hemiblock
Other ECG findings in anterior hemiblock:Other ECG findings in anterior hemiblock: Normal QRS complex (<0.12 sec) or a right Normal QRS complex (<0.12 sec) or a right
bundle branch blockbundle branch block Small Q wave followed by tall R wave in lead ISmall Q wave followed by tall R wave in lead I Small R wave followed by deep S wave in lead IIISmall R wave followed by deep S wave in lead III
High risk to develop complete heart blockHigh risk to develop complete heart block
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Anterior HemiblockAnterior HemiblockShowing 1 Block of 3 FasciclesShowing 1 Block of 3 Fascicles
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Posterior HemiblockPosterior Hemiblock
Right axis deviation with normal QRS Right axis deviation with normal QRS complex or right bundle branch blockcomplex or right bundle branch block
Other ECG findingsOther ECG findings Small R wave followed by deep S wave in lead ISmall R wave followed by deep S wave in lead I Small Q wave followed by tall R wave in lead IIISmall Q wave followed by tall R wave in lead III
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Posterior HemiblockPosterior HemiblockShowing 2 of 3 Fascicles BlockedShowing 2 of 3 Fascicles Blocked
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Bifascicular BlockBifascicular Block 2 of 3 pathways for ventricular conduction 2 of 3 pathways for ventricular conduction
blockedblocked Right bundle branch block with anterior or posterior Right bundle branch block with anterior or posterior
hemiblockhemiblock Left bundle branch blockLeft bundle branch block
Compromises myocardial contractility and Compromises myocardial contractility and cardiac outputcardiac output
May develop complete heart block suddenly May develop complete heart block suddenly
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Multilead Determination of Axis and Multilead Determination of Axis and HemiblocksHemiblocks
Identifying axis can be useful in Identifying axis can be useful in determining the presence of hemiblocksdetermining the presence of hemiblocks
Best evaluated by looking at the QRS Best evaluated by looking at the QRS complexes in leads I, II, and IIIcomplexes in leads I, II, and III
Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc. 69
Multilead Determination of Axis and Multilead Determination of Axis and HemiblocksHemiblocks
Axis is:Axis is: Normal if QRS deflection is positive in bipolar leadsNormal if QRS deflection is positive in bipolar leads Physiological left (normal in some patients) when QRS Physiological left (normal in some patients) when QRS
deflection is:deflection is:• Positive in leads I and IIPositive in leads I and II
• Negative (inverted) in lead IIINegative (inverted) in lead III
Pathological left when QRS deflection is:Pathological left when QRS deflection is:• Positive in lead IPositive in lead I
• Negative in leads II and III (indicating an anterior hemiblock)Negative in leads II and III (indicating an anterior hemiblock)
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Multilead Determination of Axis and Multilead Determination of Axis and HemiblocksHemiblocks
Right axis when QRS deflection is:Right axis when QRS deflection is: Negative in lead I, negative or positive in lead IINegative in lead I, negative or positive in lead II Positive in lead III (pathological in any adult)Positive in lead III (pathological in any adult) Indicative of posterior hemiblockIndicative of posterior hemiblock
Extreme right (“No man’s land”) when QRS Extreme right (“No man’s land”) when QRS deflection is negative in all three leadsdeflection is negative in all three leads Rhythm is ventricular in originRhythm is ventricular in origin
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Acute Coronary SyndromesAcute Coronary Syndromes
Acute myocardial infarction (AMI)Acute myocardial infarction (AMI) Unstable angina (UA)Unstable angina (UA) Treatment goalsTreatment goals
Reduce myocardial necrosisReduce myocardial necrosis Prevent major adverse cardiac eventsPrevent major adverse cardiac events Treat acute complications of ACSTreat acute complications of ACS
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AtherosclerosisAtherosclerosis
Progressive narrowing of lumen of medium and Progressive narrowing of lumen of medium and large arteries large arteries Aorta and its branches, cerebral arteries, coronary Aorta and its branches, cerebral arteries, coronary
arteriesarteries Development of thick, hard, atherosclerotic Development of thick, hard, atherosclerotic
plaques called plaques called atheromasatheromas or or atheromatousatheromatous lesionslesions Commonly found in areas of turbulent blood flowCommonly found in areas of turbulent blood flow
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AtherosclerosisAtherosclerosis——Risk FactorsRisk Factors
AgeAge Earlier in men than womenEarlier in men than women Family historyFamily history DiabetesDiabetes SmokingSmoking HypertensionHypertension HypercholesterolemiaHypercholesterolemia
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AtherosclerosisAtherosclerosis——EffectsEffects
Disrupts intimal surface, causing loss of Disrupts intimal surface, causing loss of vessel elasticity and increase in vessel elasticity and increase in thrombogenesisthrombogenesis Atheroma reduces diameter of vessel lumenAtheroma reduces diameter of vessel lumen Decreases blood supply to tissuesDecreases blood supply to tissues
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Angina PectorisAngina Pectoris
Symptom of myocardial ischemiaSymptom of myocardial ischemia ““Choking” pain in the chestChoking” pain in the chest Imbalance between myocardial oxygen supply Imbalance between myocardial oxygen supply
and demandand demand Accumulation of lactic acid and carbon dioxide Accumulation of lactic acid and carbon dioxide
in ischemic tissues of myocardiumin ischemic tissues of myocardium Metabolites irritate nerve endings and produce painMetabolites irritate nerve endings and produce pain
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Angina PectorisAngina Pectoris
CausesCauses Atherosclerotic disease of the coronary arteriesAtherosclerotic disease of the coronary arteries Temporary occlusion due to coronary artery Temporary occlusion due to coronary artery
spasm with or without atherosclerosis spasm with or without atherosclerosis • Prinzmetal's angina Prinzmetal's angina
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Angina PectorisAngina Pectoris
Pain described as pressure, squeezing, Pain described as pressure, squeezing, heaviness, or tightness in chestheaviness, or tightness in chest 30% feel pain only in chest30% feel pain only in chest Others describe as radiating to shoulders, arms, Others describe as radiating to shoulders, arms,
neck, and jaw and through to backneck, and jaw and through to back Associated signs and symptomsAssociated signs and symptoms
AnxietyAnxiety Shortness of breathShortness of breath Nausea or vomitingNausea or vomiting DiaphoresisDiaphoresis
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Stable AnginaStable Angina Usually caused by physical exertion or Usually caused by physical exertion or
emotional stressemotional stress Pain lasts 1-5 minPain lasts 1-5 min
May last as long as 15 minMay last as long as 15 min Relieved by rest, nitroglycerin, or oxygenRelieved by rest, nitroglycerin, or oxygen ““Attacks” are usually similar in natureAttacks” are usually similar in nature Always relieved by same therapyAlways relieved by same therapy
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Unstable AnginaUnstable Angina Preinfarction anginaPreinfarction angina Anginal pattern that has changed in its ease Anginal pattern that has changed in its ease
of onset, frequency, intensity, duration, or of onset, frequency, intensity, duration, or qualityquality
Includes “new onset” anginal chest painIncludes “new onset” anginal chest pain May occur during exercise or at restMay occur during exercise or at rest Pain lasts Pain lasts >>10 min10 min Less promptly relieved than stable anginaLess promptly relieved than stable angina
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Unstable AnginaUnstable Angina——Management Management
Place patient at restPlace patient at rest Administer oxygenAdminister oxygen Administer aspirin (per protocol)Administer aspirin (per protocol) IV therapy IV therapy Pharmacological therapyPharmacological therapy
NitroglycerinNitroglycerin MorphineMorphine
Monitor ECGMonitor ECG Transport as soon as possibleTransport as soon as possible
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Myocardial InfarctionMyocardial Infarction
Sudden and total occlusion or near-occlusion Sudden and total occlusion or near-occlusion of blood flowing through affected coronary of blood flowing through affected coronary arteryartery
Ischemia, injury, and necrosis of myocardium Ischemia, injury, and necrosis of myocardium distal to occlusiondistal to occlusion
Often associated with atherosclerotic heart Often associated with atherosclerotic heart disease (ASHD)disease (ASHD)
Precipitating eventsPrecipitating events
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Types and Locations of InfarctsTypes and Locations of Infarcts
Infarction distal to occluded arteryInfarction distal to occluded artery Size of infarct determined by:Size of infarct determined by:
Metabolic needs of tissue supplied by occluded Metabolic needs of tissue supplied by occluded vesselvessel
Collateral circulationCollateral circulation Time until flow is reestablishedTime until flow is reestablished
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Types and Locations of InfarctsTypes and Locations of Infarcts
Emergency careEmergency care Increasing oxygen supply Increasing oxygen supply Decreasing metabolic needs Decreasing metabolic needs Providing collateral circulationProviding collateral circulation Reestablishing perfusion to ischemic myocardium Reestablishing perfusion to ischemic myocardium
quicklyquickly
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Types and Locations of InfarctsTypes and Locations of Infarcts
Most AMIs involve ventricle or Most AMIs involve ventricle or interventricular septum, which is supplied interventricular septum, which is supplied by either of two major coronary arteriesby either of two major coronary arteries Some patients sustain damage to right ventricleSome patients sustain damage to right ventricle
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Types and Locations of InfarctsTypes and Locations of Infarcts
Anterior, lateral, or septal wall infarctionAnterior, lateral, or septal wall infarction Usually left coronary artery occlusionUsually left coronary artery occlusion
Inferior wall infarction Inferior wall infarction Usually right coronary artery occlusionUsually right coronary artery occlusion
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Myocardial InfarctionMyocardial Infarction
Three ischemic syndromes Three ischemic syndromes Based on rupture of an unstable plaque in an Based on rupture of an unstable plaque in an
epicardial arteryepicardial artery Unstable anginaUnstable angina Non-ST-elevation myocardial infarctionNon-ST-elevation myocardial infarction ST-elevation myocardial infarctionST-elevation myocardial infarction
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InfarctionInfarction Unstable anginaUnstable angina
Thrombus has not completely obstructed coronary Thrombus has not completely obstructed coronary flowflow
Intermittent ischemic episodeIntermittent ischemic episode May lead to complete occlusion and AMIMay lead to complete occlusion and AMI
Non-ST-elevation MINon-ST-elevation MI ST-segment depressionST-segment depression T-wave abnormalitiesT-wave abnormalities
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InfarctionInfarction
ST-elevation MIST-elevation MI Q-wave MIQ-wave MI
• Pathological Q wavesPathological Q waves > 5 mm in depth> 5 mm in depth > 0.04 sec in duration in > 0.04 sec in duration in
>>2 contiguous leads2 contiguous leads
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Death of MyocardiumDeath of Myocardium After blood flow to myocardium stops, cells After blood flow to myocardium stops, cells
switch to anaerobic metabolismswitch to anaerobic metabolism Produces ischemic pain (angina)Produces ischemic pain (angina)
Cells begin to swell and depolarizeCells begin to swell and depolarize If collateral flow and reperfusion are If collateral flow and reperfusion are
inadequate, much of muscle dies distal to inadequate, much of muscle dies distal to occlusion occlusion
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Area of InfarctionArea of Infarction
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Myocardial InfarctionMyocardial Infarction——DeathsDeaths
Lethal dysrhythmiasLethal dysrhythmias• VTVT
• VFVF
• Cardiac standstillCardiac standstill Pump failurePump failure
• Cardiogenic shockCardiogenic shock
• CHFCHF Myocardial tissue ruptureMyocardial tissue rupture
• Ventricle, septum, or papillary muscleVentricle, septum, or papillary muscle
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MIMI——Signs and SymptomsSigns and Symptoms
Pain is similar to anginaPain is similar to angina May radiate to arms, neck, jaw, or backMay radiate to arms, neck, jaw, or back DyspneaDyspnea AnxietyAnxiety AgitationAgitation Sense of impending doomSense of impending doom Nausea and vomitingNausea and vomiting DiaphoresisDiaphoresis CyanosisCyanosis PalpitationsPalpitations
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MIMI——Signs and SymptomsSigns and Symptoms
Chest pain often constantChest pain often constant Not altered by nitroglycerin or medications, Not altered by nitroglycerin or medications,
rest, changes in body position, or breathing rest, changes in body position, or breathing patternspatterns Onset of pain at rest in >50% of MI patientsOnset of pain at rest in >50% of MI patients Most have experienced warning anginal pain Most have experienced warning anginal pain
(preinfarction angina) hours or days before(preinfarction angina) hours or days before
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Myocardial InfarctionMyocardial Infarction——ECG FindingsECG Findings
Heart muscle unable to contract effectivelyHeart muscle unable to contract effectively Remains in depolarized stateRemains in depolarized state
Current flow between pathologically depolarized Current flow between pathologically depolarized and normally repolarized areas can produce:and normally repolarized areas can produce:• Abnormal ST segment elevationAbnormal ST segment elevation
• Ischemic ST segment depressionIschemic ST segment depression
• Normal or non-diagnostic ECG changesNormal or non-diagnostic ECG changes
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Myocardial InfarctionMyocardial Infarction——ECG FindingsECG Findings
ST-Segment Elevation MI (STEMI)ST-Segment Elevation MI (STEMI) ST segment elevation >1 mm in 2 adjacent leadsST segment elevation >1 mm in 2 adjacent leads new LBBBnew LBBB
High-Risk UA/non-ST-Elevation MI (NSTEMI)High-Risk UA/non-ST-Elevation MI (NSTEMI) ST segment depression >0.5 mm lasting 20 min.ST segment depression >0.5 mm lasting 20 min. T-wave inversion with painT-wave inversion with pain
Normal or nondiagnostic ECG changesNormal or nondiagnostic ECG changes Inconclusive changes Inconclusive changes
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Myocardial Infarction ECG ImpostersMyocardial Infarction ECG Imposters
Left bundle branch blockLeft bundle branch block Some ventricular rhythmsSome ventricular rhythms Left ventricular hypertrophyLeft ventricular hypertrophy PericarditisPericarditis Ventricular aneurysmVentricular aneurysm Early repolarizationEarly repolarization
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Myocardial InfarctionMyocardial Infarction——ManagementManagement
Oxygen Oxygen AspirinAspirin NitroglycerinNitroglycerin MorphineMorphine 12-lead ECG12-lead ECG Fibrinolytic screeningFibrinolytic screening Transport to appropriate facilityTransport to appropriate facility
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ST Segment Elevation Likely with ST Segment Elevation Likely with Acute Injury Acute Injury
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RightRight ventricleV4R, V5R, V6R
LeftLateral wallI, aVL, V5, V6
LeftAnterior wall(most lethal)
V3, V4
LeftSeptal wallV1, V2
RightInferior wall(most common)
II, III, aVF
Coronary Artery Involved
Location of InfarctionLead
ST-Elevation and Infarct LocationST-Elevation and Infarct Location
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Multilead Assessment of the Multilead Assessment of the HeartHeart
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Left Ventricular Failure (LVF) and Left Ventricular Failure (LVF) and Pulmonary EdemaPulmonary Edema
Left ventricle fails to function as an effective Left ventricle fails to function as an effective forward pumpforward pump
Causes back-pressure of blood into pulmonary Causes back-pressure of blood into pulmonary circulationcirculation
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LVF and Pulmonary EdemaLVF and Pulmonary Edema
Caused by heart disease, including:Caused by heart disease, including: IschemicIschemic ValvularValvular Hypertensive heart diseaseHypertensive heart disease
Untreated LVF leads to pulmonary edemaUntreated LVF leads to pulmonary edema
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LVFLVF——Signs and SymptomsSigns and Symptoms
Respiratory distressRespiratory distress Apprehension, agitation, confusionApprehension, agitation, confusion Cyanosis (if severe)Cyanosis (if severe) DiaphoresisDiaphoresis Adventitious lung soundsAdventitious lung sounds JVDJVD Abnormal vital signsAbnormal vital signs
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Pulmonary EdemaPulmonary Edema——ManagementManagement
Oxygen, IV, monitorOxygen, IV, monitor 12-lead ECG12-lead ECG Nitroglycerin (SBP >100)Nitroglycerin (SBP >100) FurosemideFurosemide MorphineMorphine CPAPCPAP Reversible causesReversible causes Dobutamine or dopamine for shockDobutamine or dopamine for shock
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Right Ventricular Failure (RVF)Right Ventricular Failure (RVF)
Right ventricle fails as effective forward pumpRight ventricle fails as effective forward pump Back-pressure of blood into systemic venous Back-pressure of blood into systemic venous
circulationcirculation
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RVFRVF
Causes Causes Chronic hypertension (LVF precedes RVF)Chronic hypertension (LVF precedes RVF) COPDCOPD Pulmonary embolismPulmonary embolism Valvular heart diseaseValvular heart disease Right ventricular infarctionRight ventricular infarction
RVF usually results from LVFRVF usually results from LVF
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RVFRVF
Signs and symptomsSigns and symptoms TachycardiaTachycardia Venous congestionVenous congestion
• Engorged liver, spleen, or bothEngorged liver, spleen, or both
• Venous distentionVenous distention
• Peripheral edemaPeripheral edema
Fluid accumulation in serous cavitiesFluid accumulation in serous cavities ManagementManagement
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Cardiogenic ShockCardiogenic Shock
Most extreme form of pump failureMost extreme form of pump failure Left ventricular function is so compromised Left ventricular function is so compromised
heart cannot meet metabolic needs of bodyheart cannot meet metabolic needs of body Extensive myocardial infarctionExtensive myocardial infarction
40% of left ventricle40% of left ventricle Diffuse ischemiaDiffuse ischemia
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Cardiac TamponadeCardiac Tamponade Impaired diastolic filling of heart Impaired diastolic filling of heart Increased fluid in pericardial spaceIncreased fluid in pericardial space Volume of pericardial fluid encroaches on Volume of pericardial fluid encroaches on
capacity of atria and ventricles to fill capacity of atria and ventricles to fill adequatelyadequately
Ventricular filling is mechanically limited, and Ventricular filling is mechanically limited, and stroke volume is decreasedstroke volume is decreased
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Cardiac TamponadeCardiac Tamponade
Acute onsetAcute onset TraumaTrauma
Gradual onsetGradual onset NeoplasmNeoplasm InfectionInfection Renal diseaseRenal disease HypothyroidismHypothyroidism
ManagementManagement FluidFluid PericardiocentesisPericardiocentesis
PresentationPresentation Chest painChest pain TachycardiaTachycardia EctopyEctopy JVDJVD Decreased SBPDecreased SBP Pulsus paradoxusPulsus paradoxus Muffled heart soundsMuffled heart sounds ECG changesECG changes
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Thoracic and Abdominal Thoracic and Abdominal Aortic AneurysmsAortic Aneurysms
AneurysmAneurysm Dilation of a vesselDilation of a vessel
CausesCauses Atherosclerotic disease (most common)Atherosclerotic disease (most common) Infectious disease (primarily syphilis)Infectious disease (primarily syphilis) Traumatic injuryTraumatic injury Certain genetic disorders (e.g., Marfan's Certain genetic disorders (e.g., Marfan's
syndrome)syndrome)
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Aortic AneurysmsAortic Aneurysms——Signs and Signs and SymptomsSymptoms
HypotensionHypotension SyncopeSyncope Abdominal or back Abdominal or back
painpain Tearing or rippingTearing or ripping
Low back or flank Low back or flank pain pain Radiates to thigh, Radiates to thigh,
groin, testiclegroin, testicle
Peritoneal irritationPeritoneal irritation Urge to defecateUrge to defecate Pulsatile, tender massPulsatile, tender mass Distal pulses present Distal pulses present
or absentor absent GI bleedingGI bleeding
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Branches of Aorta Branches of Aorta
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Pathogenesis of Dissecting Pathogenesis of Dissecting AneurysmsAneurysms
Medial and intimal degeneration Medial and intimal degeneration in aortic wallin aortic wall
Hemodynamic forces produce Hemodynamic forces produce tear tear
Dissecting hematoma Dissecting hematoma propagated by pulse wavepropagated by pulse wave
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Dissecting AneurysmsDissecting Aneurysms—Management—Management
Gentle handlingGentle handling OxygenOxygen MonitorMonitor IV fluidsIV fluids
Bolus if profound shockBolus if profound shock
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Acute Arterial OcclusionAcute Arterial Occlusion
Blockage of arterial flow caused by:Blockage of arterial flow caused by: TraumaTrauma EmbolusEmbolus ThrombosisThrombosis
Severity of episode depends on:Severity of episode depends on: Site of occlusionSite of occlusion Collateral circulationCollateral circulation
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Acute Arterial OcclusionAcute Arterial Occlusion Signs and symptomsSigns and symptoms
Pain in extremity Pain in extremity • May be severe and sudden in onset or absent because May be severe and sudden in onset or absent because
of paresthesiaof paresthesia PallorPallor Cool skin distal to occlusionCool skin distal to occlusion Change in sensory and motor functionChange in sensory and motor function Diminished or absent pulse distal to injuryDiminished or absent pulse distal to injury Bruit over affected vesselBruit over affected vessel Slow capillary fillingSlow capillary filling Sometimes shockSometimes shock
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Arterial OcclusionArterial Occlusion—Management—Management
Extremity occlusion is painful and limb Extremity occlusion is painful and limb threatening if blood flow is not reestablished threatening if blood flow is not reestablished within 4-8 hrswithin 4-8 hrs
Immobilize limb and transportImmobilize limb and transport Patients with mesenteric occlusionPatients with mesenteric occlusion
Manage for shock:Manage for shock:• OxygenOxygen
• IV fluidsIV fluids
Analgesics for pain controlAnalgesics for pain control
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Common Sites ofCommon Sites ofEmbolic Arterial OcclusionEmbolic Arterial Occlusion
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Venous ThrombosisVenous Thrombosis
Predisposing factorsPredisposing factors History of traumaHistory of trauma SepsisSepsis Stasis or inactivityStasis or inactivity Recent immobilizationRecent immobilization PregnancyPregnancy Birth control pillsBirth control pills MalignancyMalignancy CoagulopathiesCoagulopathies SmokingSmoking Varicose veinsVaricose veins
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Acute Deep Vein Thrombosis (DVT)Acute Deep Vein Thrombosis (DVT)
Occlusion of deep veins is serious, common Occlusion of deep veins is serious, common problemproblem
May involve any portion of deep venous May involve any portion of deep venous systemsystem More common in lower extremitiesMore common in lower extremities
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Acute DVTAcute DVT——Risk FactorsRisk Factors
Lower extremity Lower extremity traumatrauma
Recent surgeryRecent surgery Advanced ageAdvanced age Recent MIRecent MI InactivityInactivity
Previous thrombosisPrevious thrombosis Oral contraceptivesOral contraceptives CancerCancer ObesityObesity CHFCHF
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Acute DVTAcute DVT——ManagementManagement
Risk of pulmonary embolusRisk of pulmonary embolus HospitalizationHospitalization Bed restBed rest AnticoagulantsAnticoagulants
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Common Sites ofCommon Sites ofAtherosclerotic Occlusive DiseaseAtherosclerotic Occlusive Disease
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HypertensionHypertension
Resting BP: Consistently >140/90 mm HgResting BP: Consistently >140/90 mm Hg Several categories of hypertension based on Several categories of hypertension based on
level of blood pressure, symptoms, and level of blood pressure, symptoms, and urgency of need for interventionurgency of need for intervention
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Chronic HypertensionChronic Hypertension
Conditions associated with chronic, Conditions associated with chronic, uncontrolled hypertensionuncontrolled hypertension Cerebral hemorrhage and strokeCerebral hemorrhage and stroke Myocardial infarctionMyocardial infarction Renal failure (secondary to vascular changes in Renal failure (secondary to vascular changes in
the kidney)the kidney) Thoracic and/or abdominal aortic aneurysmThoracic and/or abdominal aortic aneurysm
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Hypertensive EmergenciesHypertensive Emergencies
Blood pressure increase leads to significant, Blood pressure increase leads to significant, irreversible end-organ damage within hours if irreversible end-organ damage within hours if not treatednot treated
Organs most at risk are brain, heart, and Organs most at risk are brain, heart, and kidneyskidneys
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Hypertensive EmergenciesHypertensive Emergencies
Myocardial ischemia with hypertensionMyocardial ischemia with hypertension Aortic dissection with hypertensionAortic dissection with hypertension Pulmonary edema with hypertensionPulmonary edema with hypertension Hypertensive intracranial hemorrhageHypertensive intracranial hemorrhage ToxemiaToxemia Hypertensive encephalopathyHypertensive encephalopathy
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Hypertensive EmergenciesHypertensive Emergencies——Signs and Signs and SymptomsSymptoms
Paroxysmal Paroxysmal nocturnal dyspneanocturnal dyspnea
Shortness of breathShortness of breath Altered mental Altered mental
statusstatus VertigoVertigo HeadacheHeadache EpistaxisEpistaxis
TinnitusTinnitus Changes in visual Changes in visual
acuityacuity Nausea and vomitingNausea and vomiting SeizuresSeizures ECG changesECG changes
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Hypertensive EncephalopathyHypertensive Encephalopathy
Severe hypertension produces hypertensive Severe hypertension produces hypertensive encephalopathy and cerebral hypoperfusionencephalopathy and cerebral hypoperfusion
Loss of integrity of blood-brain barrierLoss of integrity of blood-brain barrier Fluid exudation into brain tissueFluid exudation into brain tissue
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Hypertensive EncephalopathyHypertensive Encephalopathy
Progresses from:Progresses from: Severe headache, nausea, vomiting, aphasia, Severe headache, nausea, vomiting, aphasia,
hemiparesis, and transient blindnesshemiparesis, and transient blindness LaterLater
Seizures, stupor, coma, and deathSeizures, stupor, coma, and death
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Hypertensive EmergenciesHypertensive Emergencies
Supportive careSupportive care OxygenOxygen IVIV ECG monitoringECG monitoring Rapid transportRapid transport Drugs under medical supervisionDrugs under medical supervision
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Techniques for ManagingTechniques for ManagingCardiac EmergenciesCardiac Emergencies
Basic life supportBasic life support Mechanical CPR devicesMechanical CPR devices Monitor-defibrillatorsMonitor-defibrillators Implantable cardioverter-defibrillators (ICDs)Implantable cardioverter-defibrillators (ICDs) Transcutaneous cardiac pacing (TCP)Transcutaneous cardiac pacing (TCP) Advanced cardiac life support (ACLS) systemAdvanced cardiac life support (ACLS) system
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