Heart basics

- Relies on electrical conduction system

o Sends out jolts of electrical signals to the atria and ventricles causing
them to contract and relax
o Known as depolarization and repolarization
- SA node – AV node – bundle branches – Purkinjie fibers split
o SA node is located in the right atrium and is the pacemaker, cause of
atrial depolarization (contract) in right and left
o The electrical signals go to AV node in the lower part of right atrium
and is the gatekeeper, cause a delay so the atria can fully empty their
blood into ventricles
o Purkinjie fibers cause ventricles to depolarize (contract)
o Repolarization occurs
- If there is a problem with this system dysrhythmias occur like atrial fibrillation
- P = SA node = contraction of atriums
- PR segment = filling of ventricles
- QRS = contraction of ventricles
- T = relaxation of ventricles
- U = pause

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ECG strip
- Each large square has 25 smaller squares
- Each small square = 0.04 seconds horizontally and
0.1 millivolt vertically
- Each large square = 0.20 seconds
- 300 large squares = 1 minute

Systematic approach to assessing cardiac rhythms

1. Evaluate the rhythm
2. Determine the rate
3. Assess presence and configuration of P waves
4. Calculate duration of the PR interval
5. Calculate QRS duration
6. Calculate QT interval
7. Assess for changes in ST segment, T wave, or both
8. Interpret the rhythm
9. Determine clinical significance of this rhythm
10. Determine the treatment for the rhythm

Calculate HR
- Count the number of R-R intervals in 6 seconds and
multiply by 10 = approximate bpm

Dysrhythmias
- Causes:
o Cardiac conditions:
§ Conduction defects
§ Heart failure
§ Hypertrophy of cardiac muscle
§ Myocardial cell degeneration
§ Myocardial infarction
o Other conditions:
§ Acid-base imbalances
§ Alcohol, coffee, tea, tobacco
§ Connective tissue disorders
§ Drug effects or toxicity
§ Electric shock
§ Electrolyte imbalances
§ Hypoxia, shock
§ Metabolic conditions
§ Near-drowning
§ Poisoning
 - Assessment findings
o Chest, neck, shoulder, or arm pain
o Cold, clammy skin
o Decreased BP
o Decreased LOC
o Decreased SpO2
o Diaphoresis
o Dizziness, syncope
o Dyspnea
o Extreme restlessness
o Feeling of impending doom
o Irregular HR and rhythm, palpitations
o N/V
o Numbness, tingling of arms
o Pallor
o Weakness and fatigue
- Interventions
o Ensure patent airway
o Administer O2 via NC
o Establish IV access
o Apply cardiac monitoring electrodes
o Identify underlying rhythm
o Identify ectopic beats
o Monitor VS, LOC, SpO2, and cardiac rhythm
o Anticipate need for intubation if resp distress
o Prepare to initiate CPR or defibrillation

Sinus bradycardia
- SA node < 60 bpm = absolute bradycardia
- HR that is less than expected for the patient’s condition = relative bradycardia
- Signs and symptoms:
o Pale
o Cool skin
o Hypotension
o Weakness
o Angina
o Dizziness or syncope
o Confusion
o SOB
- Treatment:
o Administration of atropine (anticholinergic)
o Pacemaker therapy
Sinus tachycardia
- >100 bpm
- Signs and symptoms:
o Dizziness
o Dyspnea
o Hypotension
- Treatment is based on the underlying cause

Atrial fibrillation
- Disorganization of atrial electrical activity resulting in
loss of effective atrial contraction
- Most common dysrhythmia encountered in ER
- May be chronic or intermittent
- Occurs in patients with underlying heart disease such as
CAD…
- Acutely caused by factors such as alcohol intoxication,
caffeine use, electrolyte disturbances, stress, and cardiac
surgery
- Atrial rate may be as high as 600 bpm
- Ventricular rate can be from 50-180 bpm (>100 = atrial fibrillation with a rapid
ventricular response
- P waves are replaced by chaotic, fibrillatory waves
- Ventricular rhythm is usually irregular
- Can result in a decrease in CO
- Thrombi may form in the atria as a result of blood stasis
- Embolized clot may develop and travel to the brain, causing a stroke (risk is increased 3-
5 times with a fib.)
- Treatment:
o Goal is to decrease ventricular response and prevent cerebral embolic events
o Drugs include calcium channel blockers and beta blockers (metoprolol)
o Antidysrhythmic drugs used for conversion to and maintenance of sinus rhythm
include meds such as amiodarone

Asystole
- Total absence of ventricular electrical activity
- Depolarization does not occur
- Patients are unresponsive, pulseless, and apneic
- Usually a result of advance cardiac disease, severe cardiac conduction system
disturbance, or end-stage HF
- Treatment:
o Epinephrin
o Atropine
o CPR (but no defibrillation! Cannot shock without electricity!)
Heart failure
- Can occur from damage to heart tissue
- Unable to pump enough fluid forward, so fluid backs up
- Fluid backup increases work on the heart as it tries to keep
up and cannot
o Decreased perfusion forwards
o Increased congestion backwards
- Causes:
o Myocardial infarction
§ Dead muscle cannot pump
o Hypertension
§ Increased afterload = increased stress on heart muscle
o Valve disorders
§ Blood not moving in right direction
§ Inefficient pump
- Diagnostic tests:
o BNP (brain natriuretic peptide)
§ High when ventricles are stretched, can go as high as in the 1000s when in
severe fluid overload
o Echocardiogram
§ Measures EDV (end-diastolic volume = preload)
o CXR
§ Cardiomegaly (due to stretched ventricles and pushing fluid out which
enlarges heart’s ventricles)
§ Pulmonary edema (occurs due to fluid overload from the congestion)
- Complications:
o Volume overload
§ Pulmonary edema
§ Exacerbations
o Decreased perfusion
§ Heart
• Angina, MI
• Arrhythmias
§ Organs
• Impaired kidney function

Right sided HF
- Decreased perfusion to lungs (forward)
o Decreased oxygenation
§ Lack of gas exchange, decreased activity intolerance
- Increased congestion into the system (backwards)
o Systemic fluid overload
§ Since blood can’t get through the heart it will back up into
the neck = peripheral edema, weight gain, fatigue, nausea, increased JVD,
increased preload, liver/GI congestion
Left sided HF
- Decreased perfusion to body (forward)
o Decreased systemic perfusion
§ Pale, decreased pulses, slow cap refill, cool skin,
decreased renal perfusion (decreased urine output)
- Increased congestion in lungs (backwards)
o Pulmonary edema
§ Cough, crackles, wheezes, tachypnea, SOB
- Can be further divided:
o Systolic ventricular dysfunction:
§ Heart cannot contract forcefully enough during systole to give adequate
amounts of blood into circulation
§ Preload increases with decreased contractility
§ Afterload increases because of increased peripheral resistance
o Diastolic HF:
§ Preserved left ventricular function
§ Occurs when the left ventricle cannot relax adequately
§ Prevents the ventricle from filling with sufficient blood to ensure adequate
cardiac output

Renal effect
- With decreased perfusion to kidneys, it stimulates RAAS system, this causes:
o Water retention due to ADH and aldosterone
§ Body thinks it needs to retain fluid causing increased preload
o Vasoconstriction
§ Body wants to increase flow and BP, but this increases afterload
o Increase sympathetic nervous system activity
§ Goal being to increase HR, contraction, and flow to the kidneys
- All of this puts even more strain on an overworked heart = more stress, more volume
overload, perpetuated cycle that does not end

What to expect
- Weak
- Fatigued
- Dizzy
- Confused
- Congested
- Breathless
- Oliguria
- Decreased blood flow can cause renal failure
- Apical pulse needs to be taken for a full minute
- Monitor patient’s RR, rhythm, and character and SpO2
- Older adults are often disoriented or confused
- Crackles and wheezes
Therapeutic management
- Goal is to decrease workload on heart while increasing cardiac output
o Decrease preload
o Decrease afterload
o Increase contractility

Medications
- Diuretic = furosemide, hydrochlorothiazide
- Mineralocorticoid receptor antagonist = spironolactone
- ACE inhibitor = lisinopril, enalapril, captopril
- ARB = valsartan, candesartan, losartan
- Beta blocker = metoprolol
- Cardioselective beta blocker = bisoprolol fumarate
- CCB = dihydropyridines: amlodipine
- Nonspecific beta blocker = carvedilol

Patient education
- Diet and lifestyle changes
- Medication instructions
- Activity restrictions
- Frequent follow-ups
- Nutritional therapy:
o Detailed diet history
o Low sodium content (2g/day)
Vascular disorders

Peripheral vascular disease

- Assessment:
o Various positions that help alleviate discomfort or
pain
o Explanation of the pain
o Skin (color, temp, nails)
o Edema
o Lesions
- 6 P’s
o Pain, pulses, paralysis, paresthesia, pallor, polar, safety, lifestyle, wound
care, cap refill
- Diagnostics:
o Ultrasound
o ABI (artery-brachial index): BP is taken in the ankle and arm, and then compared,
diagnosed if the systolic BP in the ankle divided by the systolic BP in the arm is
less than 0.9
§ Claudication often occurs with an ABI between 0.4 and 0.9
§ Rest pain is seen between 0.2 and 0.4
§ Ulcers and gangrene between 0 and 0.4
- Peripheral venous disease
o Assessment:
§ Elevation of legs decreases swelling and helps blood flow
• Dangling creates pooling
§ Heavy, dull, throbbing, achy
§ Pain is worse when standing or sitting for long periods
§ *compression stockings
§ Warm to touch
§ Thick, tough skin
§ Brownish-coloured
§ Pulses present and normal
§ Edema present (worse at end of day)
§ Lesions in medial parts of lower legs and medial ankle region
• Appears swollen, with drainage and granulation
• Edges are regular, depth is shallow
- Peripheral arterial disease
o Progressive narrowing of arteries that supply peripheral
tissues and organs, which typically occludes:
§ Distal abd aorta
§ Iliac arteries (the internal, common, and/or external
arteries)
§ Common femoral artery (less likely)
o Targets large and medium-sized arteries – same arteries
targeted by atherosclerosis and arteriosclerosis
o Usually occurs 2 degree to atherosclerosis and
arteriosclerosis
o Assessment:
§ Dangling the legs down helps pain
• Elevation makes it worse!
• Helps move O2 down
§ Sharp pain
§ Activity causes severe pain in calf, muscles, thighs, buttocks…
• Because the muscle is being deprived of blood flow due to the
peripheral arterial disease
§ Cool to touch
§ Thin, dry/scaly skin
§ Hairless
§ Thick toenails
§ Dangle legs – rubor
§ Elevate legs – pale
§ Pulses poor or even absent
§ No edema
§ Lesions at ends of toes, dorsum, lateral malleolus
• Little drainage, limited granulation tissue
• Deep ulcer, noticeable margins, and edges
Aortic aneurysms
- Aneurysm: is a balloon-like bulge in the arterial wall –
permanent, localised, outpuching or dilation of blood
vessel
- Risk factors:
o Congenital disorder
o Trauma
o Infection (HIV, STIs)
o FHx
o PAD
o Disease which damages and weakens the arterial
wall – atherosclerosis HTN, increased cholesterol,
obese or overweight, smoking
o Males are at higher risk
- Clinical manifestations:
o Asymptomatic (may discover during an x-ray, CT,
ultrasounds, abdominal surgery
o Pulsatile mass in the periumbilical area slightly to the left
of the midline; bruits audible with stetho over aneurysm;
may mimic pain associated with other abdo or back pain
o Thoracic: CP radiates to back
o Abdominal: abdo/back pain, bruits
o Cerebral: H/A, dizziness, ALOC, N/V
o On occasion, embolization is caused by plaque released by an
aneurysm, even a small one. This can cause the “blue toe
syndrome” in which patchy mottling of the feet and toes occurs
in the presence of palpable pedal pulses
- Complications:
o Increase risk with smokers
o Most serious is rupture of the aneurysm
§ Leaks into the retroperitoneal space – severe back pain
and may or may not have back or flank ecchymosis
o in cases in which blood from a rupture leaks into thoracic or
abdominal cavity, more than 90% of patients die from massive
hemorrhage
- Diagnositic studies:
o Chest radiographs: reveal abnormal widening of the thoracic aorta
o Electrocardiography: to rule out MI
o Echocardiography: to assess function of aortic valve
o Ultrasonography: useful for aneurysm screening and monitoring aneurysm size
o CT scan: the most accurate test for determining length and cross-sectional
diameter and the presence of thrombus in the aneurysm, determining what type of
surgial repair should be done
o Magnetic resonance imagine (MRI): also may be used to diagnose and assess
location and severity of aneurysms
 o Angiography: anatomical mapping of the aortic system by contrast imaging,
provides information about the involvement of intestinal, renal, or distal vessels,
useful if a suprarenal or thoraco-abdominal aneurysm is suspected
- Collaborative care:
o Early detection, decrease risk factors
o <5.5cm, identify RF, monitor with US, CT
o Surgical repair >5.5cm
§ Open aortic bypass graft
§ Endovas graft – stent
§ Coiling
o Pre op teaching
o Post op care
§ Neuro status
§ Heart monitor
§ Peripheral and renal perfusion
§ Post op ileus (NGT)

Acute arterial ischemia

- Sudden interuption in arterial blood supply to a tissue, organ, or extremity that can result
in tissue death
- Clinical manifestations:
o 6 P’s
- Oral anticoagulants (warfarin)
- Parenteral anticoagulants (heparin)
- Thrombolytics

Raynaud’s phenomenon
- Episodic vasospastic disorder of small cutaneous arteries, almost always attacks small
arteries and arterioles of hands and feet (rarely earlobes, nose, lips)
- Occurs primarily in young women (15-40 y.o)
- Vasospasm results from an exaggerated response to sympathetic nervous system
stimulation
- Other contributing factors include occupation-related trauma and pressure to the
fingertips
- Clinical indicators:
o Downtream ischemia
o After the vasospasm releases, the artery pops back to normal size and blood flow
returns
o Another round of throbbing pain, typically occurs as the blood comes back to the
ischemic tissue
o Pallor can change to cyanosis – after vasospasm relaxes, arterial blood floods
back in and may cause erythema
o May present with multi-colored digits
o Attacks may last minutes to hours (not usually creating permanent damage
- Triggers:
o Exposure to cold or strong emotion (anything that causes release of catcholamines
 o Mild heat can bring relief
- Comorbidities:
o Does not interfere with lifespan
o Increased risk of:
§ Migraine headaches
§ Pulmonary hypertension
§ Unexplained angina
- Primary:
o More common
o Poorer physical and mental health
- Secondary:
o In association with autoimmune diseases
- Collaborative care:
o Patient education, prevent recurrent episodes
o Wear loose, warm clothing, including gloves when using the fridge or freezer
o Avoid temperature extremes
o Immersing hands in warm water often decreases the vasospasm
o Stop using all tobacco products and avoid caffeine and other drugs that have
vasoconstrictive effects
o Biofeedback, relaxation training, and stress management
o CCB (cardizem) – relaxes smooth muscles of arterioles by blocking influx of
calcium into the cells, thus reducing frequency and severity of vasospastic attacks
o Phosphodiesterase-5 inhibitors – vasodilating drug in pulmonary HTN
o Severe refractory cases may need sympathectomy: cut sympathetic nerve fibers
supplyinh affected areas
o Necrotic areas may require surgical debridement or even amputation

Amputation
- Most often involves a limb or part of it like a digit, can also involve a portion of the nose
or ears
- Causes:
o Trauma
o To prevent or manage a condition such as tissue death
o Gangrene causes by PVD
o Neurological conditions like diabetic neuropathy
o Infections like osteomyelitis
o Thermal injuries
o Cancer
o Congenital limb disorders
- Complications:
o Local or wound pain
o Neuroma (tender thickening of a nerve stump in the scar region after amputation)
o Upon palpation, pts experience sharp shooting pain
o Phantom limb (may perceive unpleasant sensations like tingling or sharp pain in
limb that has been amputated)
 o Contractures – where affected tissues like skin, muscles, ligaments become stiff
and fibrous, leading to restrictions of movement
o Local infections of the amputation stump (most often the bacteria colonizing the
skin) – can lead to sepsis
o May experience psychological complications, such as grieving over the loss of the
body part, as well as depression, decreased self-esteem
- Collaborative care:
o Post op care, monitor complications, provide emotional
support
o First 24 hrs: elevate extremity to decrease swelling
o After 24 hrs: position pt in prone position 2x/day for 20-30
mins to prevent flexion contractures of the hip
o Gently massage skin of residual limb towards the suture
line to promote circulation, and to prevent scar tissue to
adhering to underlying bone
o Apply compression bandage using figure 8 technique
o Frequently monitor level of pain, and administer prescirbed analgesics as needed
o Institute fall precautions, collaborate with physical therapist to implement early
mobility and strengthening exercises
o Assess surgical site for complicaitons: bleeding, infection, changes in color, temp,
sensation
o Report if bright red bleeding, redness, purulent drainage or foul odour at the
incision site, if the stump becomes cold or blue, if numbness or tingling of the
extremity
o Promote accepting and supportive care environment and enourage pt and family
to express their feelings and grief over lost limb and changes in body image
o Encourage them to look at, feel, participate in the care of the residual limb
o Ennsure a referral for occupational therapy and rehab services is in place, and that
counseling is available