Cardiovascular Emergencies – Part II

Cardiovascular Cardiovascular Emergencies – Emergencies –

Part IIPart II

Acute Aortic DissectionAcute Aortic Dissection Uncommon but lethal!Uncommon but lethal! Tear in the intimal Tear in the intimal

layer of the aorta that layer of the aorta that results in a false lumen results in a false lumen that is usually that is usually anterograde in nature.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

Acute Aortic DissectionAcute Aortic Dissection

The most common The most common and most lethal and most lethal acute aortic acute aortic dissection, which dissection, which accounts for 2/3 of accounts for 2/3 of all dissections, all dissections, occurs where?occurs where?

Acute Aortic DissectionAcute Aortic Dissection Most common in men Most common in men

between the ages of 60 between the ages of 60 & 70& 70

Factors:Factors:• hypertensionhypertension• hereditary defects of hereditary defects of

connective tissue connective tissue (Marfan’s)(Marfan’s)

pregnancypregnancy blunt traumablunt trauma iatrogenic factors (intra-iatrogenic factors (intra-

arterial catheterization)arterial catheterization)

Acute Aortic DissectionAcute Aortic DissectionSUBJECTIVE DATASUBJECTIVE DATA HistoryHistory Pain – sudden, sharp, tearing, Pain – sudden, sharp, tearing,

excruciating, medications may not excruciating, medications may not relieve, substernal (ascending), relieve, substernal (ascending), back/flank (descending)back/flank (descending)

SyncopeSyncope Altered LOCAltered LOC Paraplegia Paraplegia

Acute Aortic DissectionAcute Aortic DissectionOBJECTIVE DATAOBJECTIVE DATA Physical ExamPhysical Exam - variable BPs on right vs left- variable BPs on right vs left - decreased peripheral pulses/- decreased peripheral pulses/

peripheral cyanosisperipheral cyanosis - murmurmurmur - pallor, oliguria, altered LOC,- pallor, oliguria, altered LOC, - BP: hyper with distal dissection, - BP: hyper with distal dissection,

hypo with proximalhypo with proximal - extreme pain- extreme pain

Acute Aortic DissectionAcute Aortic DissectionOBJECTIVE DATAOBJECTIVE DATA DiagnosticsDiagnostics - CBC (Hct tends to fall, WBC- CBC (Hct tends to fall, WBC 12,000-20,000) 12,000-20,000) T&C,BUN/CreatinineT&C,BUN/Creatinine - EKG:- EKG:

Normal in 1/3, LV Normal in 1/3, LV hypertrophy if hx of HTN, hypertrophy if hx of HTN, signs of MI if proximal signs of MI if proximal dissection dissection

--


CXR: CXR:

-widened aortic silhouette -widened aortic silhouette

-widened mediastinum,-widened mediastinum,

-left-sided pleural effusion-left-sided pleural effusion

Acute Aortic DissectionAcute Aortic Dissection Diagnostics cont.Diagnostics cont.

- CT Scan- CT Scan

Acute Aortic DissectionAcute Aortic DissectionINTERVENTIONSINTERVENTIONS ABCABC Pain reliefPain relief Large bore IVs Large bore IVs

• – – minimum of two sitesminimum of two sites MonitoringMonitoring Medications: Medications:

1)1) to lower arterial BP: to lower arterial BP:

nitroprusside, labetalolnitroprusside, labetalol


Medications cont:Medications cont:

2) To decrease contraction force: 2) To decrease contraction force:

beta blockers preferred, may give beta blockers preferred, may give calcium channel blockers if beta calcium channel blockers if beta blockers contraindicatedblockers contraindicated

3) To relieve pain: Morphine3) To relieve pain: Morphine Position of comfortPosition of comfort IVF in hypotensive settingIVF in hypotensive setting FoleyFoley


Anticipate:Anticipate:

ED thoracotomy, immediate need ED thoracotomy, immediate need for OR, arterial & central for OR, arterial & central venous cannulationvenous cannulation

Therapeutics:Therapeutics:

Explain all procedures to Explain all procedures to patient/family, maintain calm, patient/family, maintain calm,

allow family at bedside if possibleallow family at bedside if possible

Acute PericarditisAcute Pericarditis Result of inflammation of the Result of inflammation of the

pericardium that may extend to pericardium that may extend to adjacent structures and may produce adjacent structures and may produce exudate.exudate.

Factors:Factors: - - infections: idiopathic, viral, infections: idiopathic, viral,

bacterial, fungalbacterial, fungal - connective tissue disease - connective tissue disease

(lupus, rheumatoid)(lupus, rheumatoid) - renal disease- renal disease - neoplastic disorders- neoplastic disorders - tissue injury- tissue injury

Acute PericarditisAcute Pericarditis

Acute pericarditis is more Acute pericarditis is more common in which gender and common in which gender and which age group?which age group?


SUBJECTIVE DATASUBJECTIVE DATA

General malaise, fever, chills, weight General malaise, fever, chills, weight lossloss

Dyspnea, coughDyspnea, 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

Acute PericarditisAcute PericarditisSUBJECTIVE DATA cont.SUBJECTIVE DATA cont. Medical History may Medical History may

include:include:• TB, congenital anomalies, TB, congenital anomalies,

immune disorders, MI, immune disorders, MI, neoplastic disease, drug neoplastic disease, drug use, uremia, cardiac use, uremia, cardiac surgery, cardiac trauma, surgery, cardiac trauma, infectionsinfections

Acute PericarditisAcute PericarditisOBJECTIVE DATAOBJECTIVE DATA Physical ExamPhysical Exam

- pericardial friction rub (hallmark) – - pericardial friction rub (hallmark) – heard bestheard best

at the left lower sternum during at the left lower sternum during end expirationend expiration

with patient leaning forwardwith patient leaning forward

- tachycardia, fever, tachypnea- tachycardia, fever, tachypnea


DiagnosticsDiagnostics - - EKG: FOUR STAGES (best seen in inferior EKG: FOUR STAGES (best seen in inferior

leads) leads) 1) ST elevation (early) with upright T waves,1) ST elevation (early) with upright T waves, 2) T wave flattens and ST returns to baseline2) T wave flattens and ST returns to baseline 3) T wave inversion3) T wave inversion 4) T wave returns to normal (weeks to months)4) T wave returns to normal (weeks to months) - Lab: CBC, BUN/Cr, Electrolytes, cultures, UA - Lab: CBC, BUN/Cr, Electrolytes, cultures, UA - CXR: helpful to detect pericardial effusion or- CXR: helpful to detect pericardial effusion or potential etiologypotential etiology - Echocardiogram: most accurate in detecting!!- Echocardiogram: most accurate in detecting!!

Acute PericarditisAcute PericarditisINTERVENTIONSINTERVENTIONS Supplemental O2, cardiac Supplemental O2, cardiac

monitoringmonitoring Position of comfortPosition of comfort Anti-inflammatory medicationsAnti-inflammatory medications Pericardiocentesis if necessaryPericardiocentesis if necessary Labs as orderedLabs as ordered Antibiotics as orderedAntibiotics as ordered


INTERVENTIONS contINTERVENTIONS cont Monitor/reassessMonitor/reassess Therapeutics:Therapeutics:

• maintain calmmaintain calm• explain all proceduresexplain all procedures• allow family at bedside allow family at bedside

if possible if possible• reassurancereassurance

Infective EndocarditisInfective EndocarditisInfection of the endocardium and heart valvesInfection of the endocardium and heart valves SBE SBE

• subacute bacterial endocarditis usually subacute bacterial endocarditis usually occurs in patients with congenital or acquired occurs in patients with congenital or acquired valvular disease; patients are less toxicvalvular disease; patients are less toxic

ABE ABE • acute bacterial endocariditis usually affects acute bacterial endocariditis usually affects

normal heart valves and has a greatly normal heart valves and has a greatly accelerated pace of development; patients accelerated pace of development; patients are extremely toxic with metastatic are extremely toxic with metastatic infections.infections.

Infective EndocarditisInfective Endocarditis Infective agents (most common):Infective agents (most common):

- ABE: - ABE: staphylococcus aureusstaphylococcus aureus

- - SBE: SBE: streptcoccus viridansstreptcoccus viridans Risk factors:Risk factors:

- Valvular disease, congenital - Valvular disease, congenital heart defects, rheumatic heart heart defects, rheumatic heart disease, prosthetic heart valves, disease, prosthetic heart valves, IV drug abusers, LT vascular IV drug abusers, LT vascular access cathetersaccess catheters

Infective EndocarditisInfective Endocarditis General pathophysiology:General pathophysiology:

• platelets and fibrin deposit on abnormal platelets and fibrin deposit on abnormal endotheliumendothelium

• organisms adhere and colonization beginsorganisms adhere and colonization begins• microorganisms or fragments shed into bloodmicroorganisms or fragments shed into blood• infarction or infection can occur at any distal infarction or infection can occur at any distal

sitesite• infection of cardiac tissue can lead to infection of cardiac tissue can lead to

progressive heart failure, conduction progressive heart failure, conduction disturbances, and dysrhythmias.disturbances, and dysrhythmias.

Infective EndocarditisInfective Endocarditis

Which age population Which age population is infective is infective

endocariditis rarely endocariditis rarely seen in?seen in?

Infective EndocarditisInfective EndocarditisSUBJECTIVE DATASUBJECTIVE DATA Fever: SBE – low grade, ABE – 102 Fever: SBE – low grade, ABE – 102

degrees Fdegrees F Anorexia, weight loss, night sweatsAnorexia, weight loss, night sweats Arthralgia, myalgia, fatigue, malaiseArthralgia, myalgia, fatigue, malaise Dyspnea, cough, pleuritic chest pain, Dyspnea, cough, pleuritic chest pain,

hemoptysishemoptysis HA, signs of stroke, confusionHA, signs of stroke, confusion Abdominal and back painAbdominal and back pain


Cardiac surgeryCardiac surgery Congenital or Congenital or

aquired heart valve aquired heart valve diseasedisease

IV drug useIV drug use Rheumatic heart Rheumatic heart

diseasedisease

Cardiac pacemakerCardiac pacemaker Recent GI or GU Recent GI or GU

disorder with valve disorder with valve diseasedisease

Prosthetic valves Prosthetic valves with recent dental with recent dental procedures without procedures without prophylactic ATXprophylactic ATX

Subjective Data Suspect if history of:


OBJECTIVE DATAOBJECTIVE DATA Fever – may be absent in elderly, chronic Fever – may be absent in elderly, chronic

renalrenal MurmurMurmur ““Janeway lesions” - petechial lesions on Janeway lesions” - petechial lesions on

hands, feet; “Roth’s Spots” on ophthalmic hands, feet; “Roth’s Spots” on ophthalmic exam; splinter hemorrhages on nails; exam; splinter hemorrhages on nails; “Osler’s nodes” – painful lesions of “Osler’s nodes” – painful lesions of fingertips; petechiae fingertips; petechiae

Splenomegaly, hematuria, proteinuria, Splenomegaly, hematuria, proteinuria, clubbing with LT SBE, neurological changesclubbing with LT SBE, neurological changes


DIAGNOSTICSDIAGNOSTICS Blood cultures – most important in Blood cultures – most important in

decision making process! decision making process! CBC (anemia common with SBE), BUN/Cr, CBC (anemia common with SBE), BUN/Cr,

Electrolytes, Glucose, Sed rate (elevated in Electrolytes, Glucose, Sed rate (elevated in both types), UAboth types), UA

EKG – conduction abnormalities may be EKG – conduction abnormalities may be present with septal abscesspresent with septal abscess

Echocardiogram – can view vegetation and Echocardiogram – can view vegetation and amount of dysfunctionamount of dysfunction

Head CTHead CT

Infective EndocarditisInfective EndocarditisINTERVENTIONSINTERVENTIONS ABC/monitoring/reassessmentsABC/monitoring/reassessments IV and NS at TKOIV and NS at TKO Labs as ordered – especially MULTIPLE Labs as ordered – especially MULTIPLE

blood cultures!blood cultures! Medications: Anti-pyretics, antibioticsMedications: Anti-pyretics, antibiotics Therapeutics – family at bedside, calm, Therapeutics – family at bedside, calm,

etc.etc.

Acute Arterial OcclusionAcute Arterial Occlusion Caused by acute disruption of Caused by acute disruption of

blood flow from an embolism blood flow from an embolism (most common), thrombosis, or (most common), thrombosis, or trauma.trauma.

Majority of emboli lodge in Majority of emboli lodge in femoral artery.femoral artery.

Leads to ischemia in areas/tissues Leads to ischemia in areas/tissues supplies by the affected arterysupplies by the affected artery

Immediate recognition and Immediate recognition and treatment required to maintain treatment required to maintain limb or organ viability.limb or organ viability.

Acute Arterial OcclusionAcute Arterial Occlusion

Approximately 80% of emboli Approximately 80% of emboli originate in the __________.originate in the __________.

Acute Arterial OcclusionAcute Arterial OcclusionSUBJECTIVE DATASUBJECTIVE DATA Pain Pain

• with movement or rest, burning, throbbing, with movement or rest, burning, throbbing, radiates distal to occlusion, excruciating, relentlessradiates distal to occlusion, excruciating, relentless

Coldness, numbnessColdness, numbness ParalysisParalysis Past Medical HX:Past Medical HX:

• MI, Rheumatic heart disease, a-fib, cardiac MI, Rheumatic heart disease, a-fib, cardiac surgery, LV aneurysm, chronic CHF, extremity surgery, LV aneurysm, chronic CHF, extremity trauma, recent placement of intra-atrial catheters.trauma, recent placement of intra-atrial catheters.

Acute Arterial OcclusionAcute Arterial OcclusionOBJECTIVE DATAOBJECTIVE DATA Pallor, cyanosis, mottled, coldnessPallor, cyanosis, mottled, coldness Pulseless (distally), paresthesia, Pulseless (distally), paresthesia,

paralysisparalysis Tenderness on palpation, muscle Tenderness on palpation, muscle

rigor with prolonged ischemiarigor with prolonged ischemia PetechiaePetechiae

Acute Arterial OcclusionAcute Arterial Occlusion

DIAGNOSTICSDIAGNOSTICS PT, PTT, CBCPT, PTT, CBC EKGEKG

Acute Arterial OcclusionAcute Arterial OcclusionINTERVENTIONSINTERVENTIONS Elevate HOB (allow for Elevate HOB (allow for

increased increased flow to ischemic extremityflow to ischemic extremity

Anticoagulants as orderedAnticoagulants as ordered

Acute Arterial OcclusionAcute Arterial OcclusionINTERVENTIONS contINTERVENTIONS cont Monitor and reassess (especially the 5 Ps)Monitor and reassess (especially the 5 Ps) Position of comfortPosition of comfort Warm environment (DO NOT apply heat to Warm environment (DO NOT apply heat to

area!)area!) Maintain extremity at level position (DO Maintain extremity at level position (DO

NOT elevate)NOT elevate) Explain procedures and allow family as Explain procedures and allow family as

ableable

Venous ThrombosisVenous Thrombosis An occlusion of a vein by a blood An occlusion of a vein by a blood

clot, commonly of the lower clot, commonly of the lower extremities, often involves extremities, often involves inflammation.inflammation.

Etiology – “Virchow’s Triad”Etiology – “Virchow’s Triad”

- integrity of veins, stasis of blood flow, & - integrity of veins, stasis of blood flow, & hypercoagulability stateshypercoagulability states

Factors: age > 40, cardiac disease, Factors: age > 40, cardiac disease, malignancy, hx of hypercoag., and use of malignancy, hx of hypercoag., and use of estrogens and BCPsestrogens and BCPs

Venous Venous ThrombosisThrombosis

The major The major complication complication

associated with associated with venous venous

thrombosis is thrombosis is ?? emboli.emboli.

Venous ThrombosisVenous ThrombosisSUBJECTIVE DATASUBJECTIVE DATA Pain – aching, localized at point of occlusion, Pain – aching, localized at point of occlusion,

constant, worse with walkingconstant, worse with walking

Swelling, deep muscle tenderness, feverSwelling, deep muscle tenderness, fever

Medical HxMedical Hx Recent surgery or anesthesia, recent traumatic Recent surgery or anesthesia, recent traumatic

event, postpartum, prolonged bedrest, heart event, postpartum, prolonged bedrest, heart failure, malignancy, obesity, BCPs, recent MI, failure, malignancy, obesity, BCPs, recent MI, thrombotic disease, hematological disordersthrombotic disease, hematological disorders

Venous ThrombosisVenous ThrombosisOBJECTIVE DATAOBJECTIVE DATA Erythema, swelling, indurations, Erythema, swelling, indurations,

warmthwarmth Deep muscle tendernessDeep muscle tenderness Asymmetry between extremitiesAsymmetry between extremities FeverFever Positive Homan’s signPositive Homan’s sign

Venous ThrombosisVenous ThrombosisDIAGNOSTICSDIAGNOSTICS CBC, Sed rate, PT/PTTCBC, Sed rate, PT/PTT Doppler US flow studyDoppler US flow study

Venous ThrombosisVenous Thrombosis

INTERVENTIONSINTERVENTIONS Position of comfort, elevate effected Position of comfort, elevate effected

extremity, bed restextremity, bed rest Analgesia, anticoagulants, and Analgesia, anticoagulants, and

thrombolytics as ordered thrombolytics as ordered Warm, moist compresses to areaWarm, moist compresses to area Elastic stockings or ACE wraps as orderedElastic stockings or ACE wraps as ordered I&O, reassessmentsI&O, reassessments

PVDPVD Major cause is arteriosclerosis, or Major cause is arteriosclerosis, or

hardening of the large and hardening of the large and medium-sized arteries.medium-sized arteries.

Symptoms related to the decrease Symptoms related to the decrease in blood flow to the specific areas; in blood flow to the specific areas; Worsen as disease worsens.Worsen as disease worsens.

Factors: Heredity, male sex, Factors: Heredity, male sex, increasing age, cigarette smoking, increasing age, cigarette smoking, HTN, & hyperlipidemia.HTN, & hyperlipidemia.

Other types: Raynaud’s Disease & Other types: Raynaud’s Disease & Buerger’s DiseaseBuerger’s Disease

PVDPVDRAYNAUD’SRAYNAUD’S Episodic intense vasospasms of the Episodic intense vasospasms of the

digits in response to cold or stress.digits in response to cold or stress. Affects women more than men.Affects women more than men. Vasospasm produces ischemia, Vasospasm produces ischemia,

which produces pallor followed by which produces pallor followed by cyanosis, coldness, and numbness cyanosis, coldness, and numbness of the affected digit. of the affected digit.

As spasm resolves, there is an As spasm resolves, there is an intense rubor and throbbing pain intense rubor and throbbing pain prior to digit returning to normal.prior to digit returning to normal.

PVDPVD

BUERGER’S DISEASEBUERGER’S DISEASE Inflammatory disorder characterized by Inflammatory disorder characterized by

thrombous formation in usually medium thrombous formation in usually medium sized arteries of the lower leg and foot.sized arteries of the lower leg and foot.

Men affected more than women.Men affected more than women. Results in ischemia, pain, intermittent Results in ischemia, pain, intermittent

claudication, decreased or absent pulses, claudication, decreased or absent pulses, and changes in skin color.and changes in skin color.

Skin becomes thin and shiny, hair growth Skin becomes thin and shiny, hair growth retarded, nails thicken, and retarded, nails thicken, and gangrene/ulcerations may develop.gangrene/ulcerations may develop.

PVDPVDSUBJECTIVE DATASUBJECTIVE DATA Pain – cold environment, stress, exercise, Pain – cold environment, stress, exercise,

relieved by removal of agonist, severe, relieved by removal of agonist, severe, throbbingthrobbing

Numbness, tinglingNumbness, tinglingOBJECTIVE DATAOBJECTIVE DATA Cold to touch, decreased/absent pulses, Cold to touch, decreased/absent pulses,

pallor, cyanosis, ruborpallor, cyanosis, rubor Thin, shiny skin; thickened nails; Thin, shiny skin; thickened nails;

ulcerations/ necrosisulcerations/ necrosis

PVDPVD

DIAGNOSTICSDIAGNOSTICS CBCCBC Doppler studiesDoppler studies

PVDPVD

INTERVENTIONSINTERVENTIONS Stop precipitating factorsStop precipitating factors Vasodilators (calcium channel blockers or Vasodilators (calcium channel blockers or

adrenergic blockers) and analgesics as adrenergic blockers) and analgesics as orderedordered

Reassess 5 P’sReassess 5 P’s Position of comfort, DO NOT elevate Position of comfort, DO NOT elevate

affected extremityaffected extremity Warm environmentWarm environment General therapeuticsGeneral therapeutics

Myocardial ContusionMyocardial Contusion Usually a result of blunt traumaUsually a result of blunt trauma Injuries may range from petechiae to full-Injuries may range from petechiae to full-

thickness contusions to rupture of the heartthickness contusions to rupture of the heart Lesions caused are similar to that of acute MI Lesions caused are similar to that of acute MI

from occlusions; major difference is amount of from occlusions; major difference is amount of hemorrhage!hemorrhage!

RARELY FATAL!RARELY FATAL! At risk for sudden dysrhythmias At risk for sudden dysrhythmias

Myocardial ContusionMyocardial Contusion

SUBJECTIVE DATASUBJECTIVE DATA Recent blunt trauma to chest, chest pain Recent blunt trauma to chest, chest pain

similar to MI but does not respond to similar to MI but does not respond to vasodilatory drugsvasodilatory drugs

Pain with inspiration usually secondary to Pain with inspiration usually secondary to fractured sternumfractured sternum

Medical HX – angina, previous MI, HTN, Medical HX – angina, previous MI, HTN, CHF, ETOH or drug use, previous CV CHF, ETOH or drug use, previous CV surgerysurgery

Myocardial ContusionMyocardial ContusionOBJECTIVE DATAOBJECTIVE DATA Exam may be normal without signs Exam may be normal without signs

of trauma or may be associated with of trauma or may be associated with severe traumasevere trauma

Contusion to chest wall, tachycardia, Contusion to chest wall, tachycardia, tachypnea, hypo- or hypertensiontachypnea, hypo- or hypertension

Signs of LV failure Signs of LV failure • cracklescrackles

Myocardial ContusionMyocardial ContusionDIAGNOSTICSDIAGNOSTICS EKG: Premature atrial or ventricular EKG: Premature atrial or ventricular

contractions, A-Fib, SA block, nodal contractions, A-Fib, SA block, nodal rhythm, AV block, nonspecific ST & T wave rhythm, AV block, nonspecific ST & T wave abnormalities, BBB (usually right), and abnormalities, BBB (usually right), and infarct pattern.infarct pattern.

Cardiac serum markersCardiac serum markers EchocardiographyEchocardiography CXRCXR

Myocardial ContusionMyocardial ContusionINTERVENTIONSINTERVENTIONS ABCABC Supplemental O2, monitoringSupplemental O2, monitoring Large bore IV (minimum of 2) & IVF as Large bore IV (minimum of 2) & IVF as

neededneeded Medicate with antidysrhymics and Medicate with antidysrhymics and

analgesics as ordered/neededanalgesics as ordered/needed Position of comfortPosition of comfort General therapeutics General therapeutics

Cardiac TamponadeCardiac Tamponade Fluid accumulation in the pericardial sac, Fluid accumulation in the pericardial sac,

which elevates intracardiac pressure, which elevates intracardiac pressure, progressive decrease in diastolic pressure, progressive decrease in diastolic pressure, and ultimately decrease in stroke volume and ultimately decrease in stroke volume and cardiac output. Prognosis dependent on and cardiac output. Prognosis dependent on etiology & timelines of intervention.etiology & timelines of intervention.

Cardiac Tamponade Cardiac Tamponade Causes:Causes:

- malignancies, pericarditis, - malignancies, pericarditis, uremia, & traumauremia, & trauma

Types:Types:

- acute: patient is in extremis; may - acute: patient is in extremis; may be less than 100cbe less than 100c

- chronic: patient not in extremis; - chronic: patient not in extremis; may be 1-2Lmay be 1-2L

Cardiac TamponadeCardiac Tamponade

Cardiac TamponadeCardiac TamponadeSUBJECTIVE DATASUBJECTIVE DATA Penetrating or blunt injury, Penetrating or blunt injury,

recent repair of cardiac lesionsrecent repair of cardiac lesions Dyspnea, anxious, chest pain, Dyspnea, anxious, chest pain,

fatigue, malaisefatigue, malaise Medical Hx:Medical Hx:

Cardiac disease, infectious or Cardiac disease, infectious or neoplastic disease, renal neoplastic disease, renal failurefailure


SUBJECTIVE DATA cont.SUBJECTIVE DATA cont. Cold, moist skin; Cold, moist skin;

cyanotic lips and cyanotic lips and digitsdigits

Decreased UODecreased UO Decreased LOC, comaDecreased LOC, coma HepatomegalyHepatomegaly

Pericardial TamponadePericardial Tamponade

OBJECTIVE DATAOBJECTIVE DATA Visual woundVisual wound Tachypnea, rales, Tachypnea, rales,

Kussmal’s sign (rise in Kussmal’s sign (rise in venous pressure with venous pressure with inspiration)inspiration)

JVD,tachycardiaJVD,tachycardia

Pericardial TamponadePericardial Tamponade

OBJECTIVE DATAOBJECTIVE DATA Beck’s Triad: Beck’s Triad:

•Venous pressure elevationVenous pressure elevation•Arterial pressure declineArterial pressure decline•Muffled heart tonesMuffled heart tones


DIAGNOSTICSDIAGNOSTICS CXRCXR Pericardiocentesis (Hct will be lower in Pericardiocentesis (Hct will be lower in

pericardial blood than venous sample & pericardial blood than venous sample & generally pericardial blood will not clot)generally pericardial blood will not clot)

EchocardiogramEchocardiogram T&C, CBCT&C, CBC EKGEKG

Cardiac TamponadeCardiac TamponadeANALYSISANALYSIS Cardiac output Cardiac output

decreased related to decreased related to impaired cardiac impaired cardiac filling and contractility filling and contractility and decreased and decreased venous return venous return secondary to secondary to increased increased intrathoracic pressureintrathoracic pressure

Cardiac TamponadeCardiac TamponadeINTERVENTIONSINTERVENTIONS ABCABC Large bore IVs (minimum of 2), Large bore IVs (minimum of 2),

IVF as neededIVF as needed Monitoring, reassessmentMonitoring, reassessment Prepare: pericardiocentesis, Prepare: pericardiocentesis,

thoracotomy, internal cardiac thoracotomy, internal cardiac massagemassage

Foley & NGFoley & NG Prepare for immediate surgical Prepare for immediate surgical

interventionintervention

Traumatic Aortic InjuryTraumatic Aortic Injury

Result from blunt or penetrating trauma - MVCs Result from blunt or penetrating trauma - MVCs are the most common causeare the most common cause

90% result in complete rupture and sudden 90% result in complete rupture and sudden death at “the scene”death at “the scene”

Tearing may occur at points of attachment or Tearing may occur at points of attachment or may be pinched between the spinal column and may be pinched between the spinal column and manubrium.manubrium.

Tears not involving the adventital layer (outer) Tears not involving the adventital layer (outer) may result in patient survival.may result in patient survival.


SUBJECTIVE DATASUBJECTIVE DATA Deceleration mechansim, blunt force Deceleration mechansim, blunt force

to chest or abdomento chest or abdomen Pain: severe, unrelenting pain in Pain: severe, unrelenting pain in

chest, midscapular, or back regionchest, midscapular, or back region Medical Hx: atherosclerotic heart Medical Hx: atherosclerotic heart

disease, prior thoracic injuries or disease, prior thoracic injuries or surgeriessurgeries


OBJECTIVE DATAOBJECTIVE DATA Dyspnea, tachypneaDyspnea, tachypnea Tachycardia, discrepancy between Tachycardia, discrepancy between

BPs in right and left arms, harsh BPs in right and left arms, harsh systolic murmur, varying degrees systolic murmur, varying degrees of shock, decreased quality of of shock, decreased quality of femoral vs radial pulsesfemoral vs radial pulses

Chest wall ecchymosis, paraplegiaChest wall ecchymosis, paraplegia

Traumatic Aortic InjuryTraumatic Aortic InjuryDIAGNOSTICSDIAGNOSTICS CXR: widened mediastinum, CXR: widened mediastinum,

obliteration of aortic knob, obliteration of aortic knob, tracheal deviation to the right, tracheal deviation to the right, presence of pleural cap, fx of presence of pleural cap, fx of 1st & 2nd ribs, depression of 1st & 2nd ribs, depression of left main stem bronchus, left main stem bronchus, deviation of esophagus to deviation of esophagus to right, shift of right main stem right, shift of right main stem bronchus up and to rightbronchus up and to right


DIAGNOSTICS contDIAGNOSTICS cont CT scanCT scan EKGEKG T&CT&C CBCCBC

Traumatic Aortic InjuryTraumatic Aortic InjuryINTERVENTIONSINTERVENTIONS ABC, monitoring, reassessmentABC, monitoring, reassessment Large bore IVs (minimum of 2), IVF as neededLarge bore IVs (minimum of 2), IVF as needed Prepare for blood transfusion & autotransfusion as Prepare for blood transfusion & autotransfusion as

neededneeded Foley & NGFoley & NG Monitor arterial pHMonitor arterial pH Prepare for immediate surgical interventionPrepare for immediate surgical intervention Administer antihypertensives & beta blockers as Administer antihypertensives & beta blockers as

ordered if surgical repair delayedordered if surgical repair delayed

Arterial TraumaArterial Trauma

Result from blunt (MVC & crush injuries) or Result from blunt (MVC & crush injuries) or penetrating (GSW & stab wounds) traumapenetrating (GSW & stab wounds) trauma

Vessels injuries include lacerations, hematomas, Vessels injuries include lacerations, hematomas, and pseudoaneurysmsand pseudoaneurysms

Neurological signs usual present due to close Neurological signs usual present due to close proximity of nervesproximity of nerves

Major consequence is ischemia distal to injury; Major consequence is ischemia distal to injury; immediate surgery required is damage is severeimmediate surgery required is damage is severe


SUBJECTIVE DATASUBJECTIVE DATA Numbness, tingling, pain, paralysisNumbness, tingling, pain, paralysis Mechanism Mechanism Medical Hx: diabetes, PVDMedical Hx: diabetes, PVD

Arterial TraumaArterial TraumaOBJECTIVE DATAOBJECTIVE DATA Hemorrhage from wound, varying stages Hemorrhage from wound, varying stages

of shock related to volume of blood loss, of shock related to volume of blood loss, pulsatile or expanding hematomapulsatile or expanding hematoma

Difference in BPs in different extremities, Difference in BPs in different extremities, prolonged cap refill, diminished or absent prolonged cap refill, diminished or absent distal pulsesdistal pulses

Pallor, paresthesia, coolness, paralysisPallor, paresthesia, coolness, paralysis


DIAGNOSTICDIAGNOSTIC Doppler studyDoppler study

Questions?????Questions?????

Cardiovascular Emergencies – Part II

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