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Shockis a life-threatening condition that occurs when the body is not getting enough blood flow. This can

damage multiple organs. Shock requires immediate medical treatment and can get worse very rapidly.

Major classes of shock include:

Cardiogenic shock(associated with heart problems) Hypovolemic shock(caused by inadequate blood volume) Anaphylactic shock(caused by allergic reaction) Septic shock(associated with infections) Neurogenic shock(caused by damage to the nervous system)

CausesShock can be caused by any condition that reduces blood flow, including:

Heart problems (such as heart attack or heart failure) Low blood volume (as with heavy bleeding or dehydration) Changes in blood vessels (as with infection or severe allergic reactions) Certain medications that significantly reduce heart function or blood pressure Shock is often associated with heavy external or internal bleeding from a serious injury. Spinal injuries

can also cause shock. Toxic shock syndrome is an example of a type of shock from an infection.

SymptomsA person in shock has extremely low blood pressure. Depending on the specific cause and type of shock,

symptoms will include one or more of the following:

Anxiety or agitation/restlessness Bluish lips and fingernails Chest pain Confusion Dizziness, lightheadedness, or faintness Pale, cool, clammy skin Low or no urine output Profuse sweating, moist skin Rapid but weak pulse Shallow breathing Unconsciousness

Intervention Check the person's airway, breathing, and circulation. If necessary, begin rescue breathing and CPR. Even if the person is able to breathe on his or her own, continue to check rate of breathing at least every

5 minutes until help arrives. If the person is conscious and does NOT have an injury to the head, leg, neck, or spine, place the person

in the shock position. Lay the person on the back and elevate the legs about 12 inches. Do NOT elevatethe head. If raising the legs will cause pain or potential harm, leave the person lying flat.

Give appropriate first aid for any wounds, injuries, or illnesses. Keep the person warm and comfortable. Loosen tight clothing.

IF THE PERSON VOMITS OR DROOLS

Turn the head to one side so he or she will not choke. Do this as long as there is no suspicion of spinalinjury.


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If a spinal injury is suspected, "log roll" him or her instead. Keep the person's head, neck, and back inline, and roll him or her as a unit.

DO NOT Do NOT give the person anything by mouth, including anything to eat or drink. Do NOT move the person with a known or suspected spinal injury. Do NOT wait for milder shock symptoms to worsen before calling for emergency medical help.

Prevention

Learn ways to prevent heart disease, falls, injuries, dehydration, and other causes of shock. If you have a knownallergy (for example, to insect bites or stings), carry an epinephrine pen. Your doctor will teach you how and

when to use it.

Once someone is already in shock, the sooner shock is treated, the less damage there may be to the person's vita

organs (such as the kidney, liver, and brain). Early first aid and emergency medical help can save a life.

Valvuloplasty

(Balloon Valvuloplasty)

What is valvuloplasty?

Valvuloplasty is performed, in certain circumstances, to open a stenotic (stiff) heart valve. In valvuloplasty, avery small, narrow, hollow tube (known as a catheter) is advanced from a blood vessel in the groin through the

aorta into the heart. Once the catheter is placed in the valve to be opened, a large balloon at the tip of the

catheter is inflated until the leaflets (flaps) of the valve are opened. Once the valve has been opened, the balloonis deflated and the catheter is removed.

Other related procedures that may be used to assess and treat the heart include resting and exercise

electrocardiogram (ECG or EKG), Holter monitor, signal-averaged ECG, cardiac catheterization, chest X-ray,

computed tomography (CT scan) of the chest, coronary artery bypass graft surgery, valve repair or replacementsurgery, echocardiography, electrophysiological studies, magnetic resonance imaging (MRI) of the heart,

myocardial perfusion scans, radionuclide angiography, and cardiac CT scan.Valves of the heart

The heart is a pump made of muscle tissue. The heart has four pumping chambers: two upper chambers, called

atria, and two lower chambers, called ventricles. The right atrium pumps blood into the right ventricle, whichthen pumps the blood into the lungs where carbon dioxide is given off and oxygen is taken into the blood.

From the lungs, the blood flows back into the left atrium, is pumped into the left ventricle, and then is pumped

through the aorta out to the rest of the body and the coronary arteries. When the atria are pumping, the

ventricles are relaxed in order to receive the blood from the atria. Once the atria have pumped their entire bloodload into the ventricles, they relax while the ventricles pump the blood out to the lungs and to the rest of the

body.

In order to keep the blood flowing forward during its journey through the heart, there are valves between each

of the heart's pumping chambers:

Tricuspid valve. Located between the right atrium and the right ventricle

Pulmonary (or pulmonic) valve. Located between the right ventricle and the pulmonary artery


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Mitral valve. Located between the left atrium and the left ventricle

Aortic valve. Located between the left ventricle and the aorta

If the heart valves become damaged or diseased, they may not function properly. Conditions that may cause

dysfunction of heart valves are valvular stenosis and valvular insufficiency (regurgitation). When one (or more)valve(s) becomes stenotic (stiff), the heart muscle must work harder to pump the blood through the valve. Some

reasons why heart valves become stenotic include infection (such as rheumatic fever or staphylococcus

infections), congenital (present at birth) valve abnormalities, and aging. If one or more valves becomeinsufficient (leaky), blood leaks backwards, which means that less blood is pumped in the proper direction.

Valvular heart disease may cause the following symptoms:

Dizziness Chest pain Breathing difficulties Palpitations Edema (swelling) of the feet, ankles, or abdomen Rapid weight gain due to fluid retention Reasons for the procedure

Valvuloplasty is performed in certain situations in order to open a heart valve that has become stiff. Not all

conditions in which a heart valve becomes stiff are treatable with valvuloplasty.

There may be other reasons for your doctor to recommend a valvuloplasty.

Risks of the procedure

Possible risks associated with valvuloplasty include, but are not limited to, the following:

Bleeding at the catheter insertion site Blood clot or damage to the blood vessel at the insertion site Significant blood loss that may require blood transfusion Infection at the catheter insertion site Cardiac dysrhythmias or arrhythmias (abnormal heart rhythms) Stroke New or worsening valve regurgitation (leakage) Rupture of the valve, requiring open-heart surgery


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You may want to ask your doctor about the amount of radiation used during the procedure and the risks related

to your particular situation. It is a good idea to keep a record of your past history of radiation exposure, such asprevious scans and other types of X-rays, so that you can inform your doctor. Risks associated with radiation

exposure may be related to the cumulative number of X-ray examinations and/or treatments over a long period

of time.

If you are pregnant or suspect that you may be pregnant, you should notify your health care provider due to risk

of injury to the fetus from a valvuloplasty. Radiation exposure during pregnancy may lead to birth defects. If

you are lactating, or breastfeeding, you should notify your health care provider.

There is a risk of allergic reaction to the dye. Patients who are allergic or sensitive to medications, contrast dyes,

iodine, or latex should notify their doctor. Also, patients with kidney failure or other kidney problems shouldnotify their doctor.

For some patients, having to lie still on the procedure table for the length of the procedure may cause some

discomfort or pain.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with

your doctor prior to the procedure.

Before the procedure

Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you mighthave about the procedure.

You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully andask questions if something is not clear.

Notify your doctor if you have ever had a reaction to any contrast dye, or if you are allergic to iodine.

Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, or anesthetic agents(local and general).

You will need to fast for a certain period of time prior to the procedure. Your doctor will notify you how long to

fast, usually overnight.

If you are pregnant or suspect that you may be pregnant, you should notify your doctor.

Notify your doctor if you have any body piercings on your chest and/or abdomen.

Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are

taking.

Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to

stop some of these medications prior to the procedure.

Your doctor may request a blood test prior to the procedure to determine how long it takes your blood to clot.

Other blood tests may be done as well.

Notify your doctor if you have a pacemaker.


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You may receive a sedative prior to the procedure to help you relax.

Based on your medical condition, your doctor may request other specific preparation.

During the procedure

A valvuloplasty may be performed as part of your stay in a hospital. Procedures may vary depending on your

condition and your doctor's practices.

Generally, a valvuloplasty follows this process:

You will be asked to remove any jewelry or other objects that may interfere with the procedure. You may wearyour dentures or hearing aids if you use either of these.

You will be asked to remove clothing and will be given a gown to wear.

You will be asked to empty your bladder prior to the procedure.

An intravenous (IV) line will be started in your hand or arm prior to the procedure for injection of medication

and to administer IV fluids, if needed.

You will be placed in a supine (on your back) position on the procedure table.

If there is excessive hair at the catheter insertion site (groin area), the hair may be clipped off.

You will be connected to an ECG monitor that records the electrical activity of the heart and monitors the heartduring the procedure using small, adhesive electrodes. Your vital signs (heart rate, blood pressure, breathing

rate, and oxygenation level) will be monitored during the procedure.

There will be several monitor screens in the room, showing your vital signs, the images of the catheter being

moved through the body into the heart, and the structures of the heart as the dye is injected.

You will receive a sedative medication in your IV before the procedure to help you relax. However, you willlikely remain awake during the procedure

Your pulses below the injection site will be checked and marked so that the circulation to the limb below the

site can be checked after the procedure.

A local anesthetic will be injected into the skin at the insertion site. You may feel some stinging at the site for a

few seconds after the local anesthetic is injected.

Once the local anesthetic has taken effect, a sheath, or introducer, will be inserted into the blood vessel. This isa plastic tube through which the catheter will be inserted into the blood vessel and advanced into the heart.

The valvuloplasty catheter will be inserted through the sheath into the blood vessel. The doctor will advance the

catheter through the vein or artery across the heart valve. Fluoroscopy (a special type of X-ray that will be

displayed on a TV monitor) may be used to assist in advancing the catheter to the heart.

Once the catheter is in place, contrast dye will be injected through the catheter into the valve in order to look at

the area. You may feel some effects when the contrast dye is injected into the IV line. These effects include aflushing sensation, a salty or metallic taste in the mouth, or a brief headache. These effects usually last for a few

moments.


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You should notify the doctor if you feel any breathing difficulties, sweating, numbness, itching, chills, nauseaand/or vomiting, or heart palpitations.

The doctor will watch the contrast dye injection on a monitor. The doctor may ask you to take a deep breath and

hold it for a few seconds.

Once the balloon is in place and has been inflated, you may notice some dizziness or even brief chest

discomfort. This should subside when the balloon is deflated. However, if you notice any severe discomfort orpain, such as chest pain, neck or jaw pain, back pain, arm pain, shortness of breath, or breathing difficulty, tell

your doctor.

The balloon may be inflated and deflated several times in order open the valve.

Once it has been determined that the valve is opened sufficiently, the catheter will be removed. The catheter

insertion site may be closed with a closure device that uses collagen to seal the opening in the artery, by the useof sutures, or by applying manual pressure over the area to keep the blood vessel from bleeding. Your doctor

will determine which method is appropriate for your condition.

If a closure device is used, a sterile dressing will be applied to the site. If manual pressure is used, the doctor (oran assistant) will hold pressure on the insertion site so that a clot will form. Once the bleeding has stopped, a

very tight bandage will be placed on the site. A small sandbag or other type of weight may be placed on top of

the bandage for additional pressure on the site, especially if the site is in the groin.

Your doctor may decide not to remove the sheath, or introducer, from the insertion site for approximately four

to six hours, in order to allow the effects of blood-thinning medication given during the procedure to wear off.You will need to lie flat during this time. If you become uncomfortable in this position, your nurse may give

you medication to make you more comfortable.

You will be assisted to slide from the table onto a stretcher so that you can be taken to the recovery area.

NOTE: If the insertion was in the groin, you will not be allowed to bend your leg for several hours. To help youremember to keep your leg straight, the knee of the affected leg may be covered with a sheet and the ends

tucked under the mattress on both sides of the bed to form a type of loose restraint.

After the procedure

In the hospital

After the procedure, you may be taken to the recovery room for observation or returned to your hospital room.

You will remain flat in bed for several hours after the procedure. A nurse will monitor your vital signs, the

insertion site, and circulation and sensation in the affected leg or arm.

You should immediately inform your nurse if you feel any chest pain or tightness, or any other pain, as well as

any feelings of warmth, bleeding, or pain at the insertion site in your leg or arm.

Bedrest may vary from two to six hours depending on your specific condition. If your doctor placed a closure

device, your bedrest may be of shorter duration.

In some cases, the sheath or introducer may be left in the insertion site. If so, the period of bedrest will be

prolonged until the sheath is removed. After the sheath is removed, you may be given a light meal.


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You may be given medication for pain or discomfort related to the insertion site or having to lie flat and still for

a prolonged period.

You will be encouraged to drink water and other fluids to help flush the contrast dye from your body.

You may feel the urge to urinate frequently because of the effects of the contrast dye and increased fluids. Youwill need to use a bedpan or urinal while on bedrest so that your affected leg or arm will not be bent.

You may resume your usual diet after the procedure, unless your doctor decides otherwise.

After the specified period of bed rest has been completed, you may get out of bed. The nurse will assist you the

first time you get up, and may check your blood pressure while you are lying in bed, sitting, and standing. Youshould move slowly when getting up from the bed to avoid any dizziness from the long period of bedrest.

You will most likely spend the night in the hospital after your procedure. Depending on your condition and the

results of your procedure, your stay may be longer. You will receive detailed instructions for your discharge andrecovery period.

At home

Once at home, you should monitor the insertion site for bleeding, unusual pain, swelling, and abnormal

discoloration or temperature change at or near the injection site. A small bruise is normal. If you notice a

constant or large amount of blood at the site that cannot be contained with a small dressing, notify your doctor.

If your doctor used a closure device for your insertion site, you will be given specific information regarding the

type of closure device that was used and how to take care of the insertion site. There will be a small knot, orlump, under the skin at the injection site. This is normal. The knot should gradually disappear over a few weeks.

It will be important to keep the insertion site clean and dry. Your doctor will give you specific bathing

instructions.

You may be advised not to participate in any strenuous activities. Your doctor will instruct you about when you

can return to work and resume normal activities.

Notify your doctor to report any of the following:

Fever and/or chills

Increased pain, redness, swelling, or bleeding or other drainage from the insertion site

Coolness, numbness and/or tingling, or other changes in the affected extremity

Chest pain or pressure, nausea and/or vomiting, profuse sweating, dizziness, and/or fainting

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular

situation.

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