Cardiovascular Emergencies –
Part II
Uncommon but lethal!Tear in the intimal
layer of the aorta that results in a false lumen that is usually anterograde in nature.
Usual locations:Usual locations:ascending aorta superior to aortic valveascending aorta superior to aortic valvedescending aorta at the ligamentum arteriosmdescending aorta at the ligamentum arteriosm
Most common in men between the ages of 60 & 70
Factors:hypertensionhereditary defects of
connective tissue (Marfan’s)
pregnancyblunt traumaiatrogenic factors (intra-
arterial catheterization)
SUBJECTIVE DATAHistoryPain – sudden, sharp, tearing, excruciating,
medications may not relieve, substernal (ascending), back/flank (descending)
SyncopeAltered LOCParaplegia
OBJECTIVE DATAPhysical Exam - variable BPs on right vs left - decreased peripheral pulses/
peripheral cyanosis - murmur - pallor, oliguria, altered LOC, - BP: hyper with distal dissection,
hypo with proximal - extreme pain
OBJECTIVE DATADiagnostics - CBC (Hct tends to fall, WBC 12,000-20,000) T&C,BUN/Creatinine - EKG:
Normal in 1/3, LV hypertrophy if hx of HTN, signs of MI if proximal dissection
-
CXR: -widened aortic silhouette -widened mediastinum, -left-sided pleural effusion
Diagnostics cont. - CT Scan
INTERVENTIONS ABC Pain relief Large bore IVs
– minimum of two sites Monitoring Medications:
1) to lower arterial BP: nitroprusside, labetalol
Medications cont: 2) To decrease contraction force: beta blockers preferred, may give
calcium channel blockers if beta blockers contraindicated
3) To relieve pain: MorphinePosition of comfortIVF in hypotensive settingFoley
Anticipate: ED thoracotomy, immediate need for
OR, arterial & central venous cannulationTherapeutics: Explain all procedures to patient/family,
maintain calm, allow family at bedside if possible
Result of inflammation of the pericardium that may extend to adjacent structures and may produce exudate.
Factors: - infections: idiopathic, viral,
bacterial, fungal - connective tissue disease
(lupus, rheumatoid) - renal disease - neoplastic disorders - tissue injury
SUBJECTIVE DATA
General malaise, fever, chills, weight loss
Dyspnea, cough
Chest Pain – deep inspiration, Chest Pain – deep inspiration, recumbent, movement, recumbent, movement, severe, sharp or dull ache, severe, sharp or dull ache, retrosternal or epigastric retrosternal or epigastric radiating to back/neck/ side, radiating to back/neck/ side, sudden, persistentsudden, persistent
SUBJECTIVE DATA cont.Medical History may
include:TB, congenital anomalies,
immune disorders, MI, neoplastic disease, drug use, uremia, cardiac surgery, cardiac trauma, infections
OBJECTIVE DATAPhysical Exam - pericardial friction rub (hallmark) – heard
best at the left lower sternum during end
expiration with patient leaning forward - tachycardia, fever, tachypnea
INTERVENTIONSSupplemental O2, cardiac
monitoringPosition of comfortAnti-inflammatory medicationsPericardiocentesis if necessaryLabs as orderedAntibiotics as ordered
INTERVENTIONS contMonitor/reassessTherapeutics:
maintain calmexplain all proceduresallow family at bedside
if possiblereassurance
Infection of the endocardium and heart valvesSBE
subacute bacterial endocarditis usually occurs in patients with congenital or acquired valvular disease; patients are less toxic
ABE acute bacterial endocariditis usually affects normal
heart valves and has a greatly accelerated pace of development; patients are extremely toxic with metastatic infections.
Infective agents (most common): - ABE: staphylococcus aureus - SBE: streptcoccus viridansRisk factors: - Valvular disease, congenital heart
defects, rheumatic heart disease, prosthetic heart valves, IV drug abusers, LT vascular access catheters
General pathophysiology:platelets and fibrin deposit on abnormal endotheliumorganisms adhere and colonization beginsmicroorganisms or fragments shed into bloodinfarction or infection can occur at any distal siteinfection of cardiac tissue can lead to progressive
heart failure, conduction disturbances, and dysrhythmias.
SUBJECTIVE DATAFever: SBE – low grade, ABE – 102
degrees FAnorexia, weight loss, night sweatsArthralgia, myalgia, fatigue, malaiseDyspnea, cough, pleuritic chest pain,
hemoptysisHA, signs of stroke, confusionAbdominal and back pain
Cardiac surgeryCongenital or
aquired heart valve disease
IV drug useRheumatic heart
disease
Cardiac pacemakerRecent GI or GU
disorder with valve disease
Prosthetic valves with recent dental procedures without prophylactic ATX
Subjective Data Suspect if history of:
OBJECTIVE DATAFever – may be absent in elderly, chronic
renalMurmur“Janeway lesions” - petechial lesions on
hands, feet; “Roth’s Spots” on ophthalmic exam; splinter hemorrhages on nails; “Osler’s nodes” – painful lesions of fingertips; petechiae
Splenomegaly, hematuria, proteinuria, clubbing with LT SBE, neurological changes
DIAGNOSTICSBlood cultures – most important in
decision making process!CBC (anemia common with SBE), BUN/Cr,
Electrolytes, Glucose, Sed rate (elevated in both types), UA
EKG – conduction abnormalities may be present with septal abscess
Echocardiogram – can view vegetation and amount of dysfunction
Head CT
INTERVENTIONSABC/monitoring/reassessmentsIV and NS at TKOLabs as ordered – especially MULTIPLE
blood cultures!Medications: Anti-pyretics, antibioticsTherapeutics – family at bedside, calm,
etc.
Caused by acute disruption of blood flow from an embolism (most common), thrombosis, or trauma.
Majority of emboli lodge in femoral artery.
Leads to ischemia in areas/tissues supplies by the affected artery
Immediate recognition and treatment required to maintain limb or organ viability.
SUBJECTIVE DATAPain
with movement or rest, burning, throbbing, radiates distal to occlusion, excruciating, relentless
Coldness, numbnessParalysisPast Medical HX:
MI, Rheumatic heart disease, a-fib, cardiac surgery, LV aneurysm, chronic CHF, extremity trauma, recent placement of intra-atrial catheters.
OBJECTIVE DATAPallor, cyanosis, mottled, coldnessPulseless (distally), paresthesia,
paralysisTenderness on palpation, muscle
rigor with prolonged ischemiaPetechiae
DIAGNOSTICSPT, PTT, CBCEKG
INTERVENTIONSElevate HOB (allow for
increased flow to ischemic extremity
Anticoagulants as ordered
INTERVENTIONS contMonitor and reassess (especially the 5 Ps)Position of comfortWarm environment (DO NOT apply heat to
area!)Maintain extremity at level position (DO
NOT elevate)Explain procedures and allow family as
able
An occlusion of a vein by a blood clot, commonly of the lower extremities, often involves inflammation.
Etiology – “Virchow’s Triad” - integrity of veins, stasis of blood flow, &
hypercoagulability statesFactors: age > 40, cardiac disease,
malignancy, hx of hypercoag., and use of estrogens and BCPs
The major complication
associated with venous
thrombosis is ? emboli.
SUBJECTIVE DATAPain – aching, localized at point of occlusion,
constant, worse with walking
Swelling, deep muscle tenderness, fever
Medical Hx Recent surgery or anesthesia, recent
traumatic event, postpartum, prolonged bedrest, heart failure, malignancy, obesity, BCPs, recent MI, thrombotic disease, hematological disorders
OBJECTIVE DATAErythema, swelling, indurations, warmthDeep muscle tendernessAsymmetry between extremitiesFeverPositive Homan’s sign
DIAGNOSTICSCBC, Sed rate, PT/PTTDoppler US flow study
INTERVENTIONSPosition of comfort, elevate effected
extremity, bed restAnalgesia, anticoagulants, and
thrombolytics as ordered Warm, moist compresses to areaElastic stockings or ACE wraps as orderedI&O, reassessments
Major cause is arteriosclerosis, or hardening of the large and medium-sized arteries.
Symptoms related to the decrease in blood flow to the specific areas; Worsen as disease worsens.
Factors: Heredity, male sex, increasing age, cigarette smoking, HTN, & hyperlipidemia.
Other types: Raynaud’s Disease & Buerger’s Disease
RAYNAUD’SEpisodic intense vasospasms of
the digits in response to cold or stress.
Affects women more than men.Vasospasm produces ischemia,
which produces pallor followed by cyanosis, coldness, and numbness of the affected digit.
As spasm resolves, there is an intense rubor and throbbing pain prior to digit returning to normal.
BUERGER’S DISEASEInflammatory disorder characterized by
thrombous formation in usually medium sized arteries of the lower leg and foot.
Men affected more than women.Results in ischemia, pain, intermittent
claudication, decreased or absent pulses, and changes in skin color.
Skin becomes thin and shiny, hair growth retarded, nails thicken, and gangrene/ulcerations may develop.
SUBJECTIVE DATAPain – cold environment, stress, exercise,
relieved by removal of agonist, severe, throbbing
Numbness, tinglingOBJECTIVE DATACold to touch, decreased/absent pulses, pallor,
cyanosis, ruborThin, shiny skin; thickened nails; ulcerations/
necrosis
DIAGNOSTICSCBCDoppler studies
INTERVENTIONSStop precipitating factorsVasodilators (calcium channel blockers or
adrenergic blockers) and analgesics as ordered
Reassess 5 P’sPosition of comfort, DO NOT elevate affected
extremityWarm environmentGeneral therapeutics
Usually a result of blunt traumaInjuries may range from petechiae to full-thickness
contusions to rupture of the heartLesions caused are similar to that of acute MI from
occlusions; major difference is amount of hemorrhage!RARELY FATAL!At risk for sudden dysrhythmias
SUBJECTIVE DATARecent blunt trauma to chest, chest pain similar to
MI but does not respond to vasodilatory drugsPain with inspiration usually secondary to fractured
sternumMedical HX – angina, previous MI, HTN, CHF, ETOH
or drug use, previous CV surgery
OBJECTIVE DATAExam may be normal without signs of trauma
or may be associated with severe traumaContusion to chest wall, tachycardia,
tachypnea, hypo- or hypertensionSigns of LV failure
crackles
DIAGNOSTICSEKG: Premature atrial or ventricular
contractions, A-Fib, SA block, nodal rhythm, AV block, nonspecific ST & T wave abnormalities, BBB (usually right), and infarct pattern.
Cardiac serum markersEchocardiographyCXR
INTERVENTIONSABCSupplemental O2, monitoringLarge bore IV (minimum of 2) & IVF as
neededMedicate with antidysrhymics and analgesics
as ordered/neededPosition of comfortGeneral therapeutics
Fluid accumulation in the pericardial sac, which elevates intracardiac pressure, progressive decrease in diastolic pressure, and ultimately decrease in stroke volume and cardiac output. Prognosis dependent on etiology & timelines of intervention.
Causes: - malignancies, pericarditis, uremia, &
traumaTypes: - acute: patient is in extremis; may be less
than 100c - chronic: patient not in extremis; may be 1-
2L
SUBJECTIVE DATAPenetrating or blunt injury, recent
repair of cardiac lesionsDyspnea, anxious, chest pain,
fatigue, malaiseMedical Hx: Cardiac disease, infectious or
neoplastic disease, renal failure
SUBJECTIVE DATA cont.Cold, moist skin; cyanotic
lips and digitsDecreased UODecreased LOC, comaHepatomegaly
OBJECTIVE DATAVisual woundTachypnea, rales,
Kussmal’s sign (rise in venous pressure with inspiration)
JVD,tachycardia
OBJECTIVE DATABeck’s Triad:
Venous pressure elevationArterial pressure declineMuffled heart tones
DIAGNOSTICSCXRPericardiocentesis (Hct will be lower in
pericardial blood than venous sample & generally pericardial blood will not clot)
EchocardiogramT&C, CBCEKG
ANALYSISCardiac output
decreased related to impaired cardiac filling and contractility and decreased venous return secondary to increased intrathoracic pressure
INTERVENTIONSABCLarge bore IVs (minimum of 2),
IVF as neededMonitoring, reassessmentPrepare: pericardiocentesis,
thoracotomy, internal cardiac massage
Foley & NGPrepare for immediate surgical
intervention
Result from blunt or penetrating trauma - MVCs are the most common cause
90% result in complete rupture and sudden death at “the scene”
Tearing may occur at points of attachment or may be pinched between the spinal column and manubrium.
Tears not involving the adventital layer (outer) may result in patient survival.
SUBJECTIVE DATADeceleration mechansim, blunt force to chest
or abdomenPain: severe, unrelenting pain in chest,
midscapular, or back regionMedical Hx: atherosclerotic heart disease,
prior thoracic injuries or surgeries
OBJECTIVE DATAOBJECTIVE DATADyspnea, tachypneaDyspnea, tachypneaTachycardia, discrepancy between BPs in Tachycardia, discrepancy between BPs in
right and left arms, harsh systolic murmur, right and left arms, harsh systolic murmur, varying degrees of shock, decreased quality varying degrees of shock, decreased quality of femoral vs radial pulsesof femoral vs radial pulses
Chest wall ecchymosis, paraplegiaChest wall ecchymosis, paraplegia
DIAGNOSTICSCXR: widened mediastinum,
obliteration of aortic knob, tracheal deviation to the right, presence of pleural cap, fx of 1st & 2nd ribs, depression of left main stem bronchus, deviation of esophagus to right, shift of right main stem bronchus up and to right
DIAGNOSTICS contCT scanEKGT&CCBC
INTERVENTIONSABC, monitoring, reassessmentLarge bore IVs (minimum of 2), IVF as neededPrepare for blood transfusion & autotransfusion as
neededFoley & NGMonitor arterial pHPrepare for immediate surgical interventionAdminister antihypertensives & beta blockers as
ordered if surgical repair delayed
Result from blunt (MVC & crush injuries) or penetrating (GSW & stab wounds) trauma
Vessels injuries include lacerations, hematomas, and pseudoaneurysms
Neurological signs usual present due to close proximity of nerves
Major consequence is ischemia distal to injury; immediate surgery required is damage is severe
SUBJECTIVE DATANumbness, tingling, pain, paralysisMechanism Medical Hx: diabetes, PVD
OBJECTIVE DATAHemorrhage from wound, varying stages of shock
related to volume of blood loss, pulsatile or expanding hematoma
Difference in BPs in different extremities, prolonged cap refill, diminished or absent distal pulses
Pallor, paresthesia, coolness, paralysis
DIAGNOSTICDoppler study