1. Bunch of Heart Stuff Chemeketa Community College EMT-Paramedic Program

2. Objectives  Left Ventricular Failure  Right Ventricular Failure  Pulmonary Edema  Cor Pulmonale  Acute Pulmonary Embolism  EKG’s

3. Left Ventricular Failure  Affects over 2% of US pop.  Disproportionate # of EMS calls  #1 Dx of inpatients >65  Incidence of CHF doubles per decade of life  Mortality Rate with CHF 8 times for men 5 times for women

4. Left Ventricular Failure  The failure of the LV to effectively pump forward  Synonymous with CHF  Acute CHF Rapid  Chronic CHF Slow Midnight Shoppers

5. LVF  Common Causes Systemic HTN –Afterload Coronary Artery Disease –Arteriosclerosis/Atherosclerosis Ischemia –Local/temporary occlusion

6. LVF  Common Causes Infarction –Permanent, necrosis Cardiomyopathy –Diseased heart muscle tissue  ETOH  Enlargement

7. LVF  Causes Volume overload –Bag of Potato Chips Severe anemia –Hypoxemia

8. LVF  Fluid will collect in LA Small & Relatively incapable  Pulmonary Vasculature Fills Pulmonary Congestion Occurs  Pulmonary Edema 2 nd to LVF

9. LVF S/S  Generalized Weakness  Fatigue  Chest Pain May be masked by respiratory complaint  Anxiety  Dyspnea

10. LVF S/S  Tachypnea  Orthopnea  Paroxysmal Nocturnal Dyspnea Elevation of pulmonary venous & cap pressures Wakening from sleep  Decrease in exercise tolerance

11. LVF S/S  Rales  Wheezes Reflex Airway Spasm Cardiac Asthma  Rhonchi (Larger airway)  Dull percussion at lung bases

14. Edema in Lungs

15. LVF S/S  Productive Cough Foamy-Blood-tinged sputum  Cyanosis  B/P Initial HTN

16. LVF S/S  Pulse Rapid Possible Dysrhythmia –Location of infarct  Diaphoresis

17. Right Ventricular Failure  Causes #1 Cause of RVF is LVF Stenosis: –Pulmonary valve –Mitral Valve Pulmonary Vascular HTN RV AMI

18. RVF – Who Cares  Inability of RV to pump forward  Overwhelmed by venous return  Backflow in systemic circulation

19. RVF – S/S  Tachycardia  Venous Congestion  Engorged Liver, spleen  JVD  Peripheral Edema Dependent Edema Pitting Edema Sacral (Bedridden)

20. RVF-S/S  Ascites Accumulation of serous fluid in peritoneal cavity – Taber’s 19 th  Pleural Effusion  Peripheral Cyanosis  Tachy if isolated RVF  Right sided hypertrophy X-ray

21. RVF – S/S  Clubbing of fingers Dx: Chronic Hypoxia with RHF  Most of the other LVF S/S also  CP  SOB  Tachypnea  Anxiety  Etc…

22. Cor Pulmonale  Cause of RVF Pulmonary Parenchymal or vascular disease  CP is a disease process  Case Scenario Explanation

23. Cor Pulmonale – Case  58 yo male  Hx of Chronic bronchitis or emphysema Typical S/S of bronchitis  Progression Deterioration of Pulmonary capillaries Alveolar Fibrosis Chronic Hypoxemia

24. Cor Pulmonale – Case  Progression caused: Increase in pulmonary artery pressures Result RV afterload increase –RV ill equipped RV Enlarges (Hypertrophy) Chronic RH HTN leads to RVF

25. Cor Pulmonale – Case  Patient displays all signs of: RVF Initial causative pulmonary condition  Voila’

26. Treatment of RVF & LVF  CHF a circumstance not a Dx  Treatment objectives Decrease myocardial: –Workload –Oxygen demand Increase force & efficiency of contraction Reduce fluid retention

27. Tx  Decrease Workload No Physical activity Sitting upright Oxygen –Pt may tolerate BVM Morphine

28. Tx  Vasodilatory Therapy (Nitrates) –AMI reperfusion –Container expansion reduces preload  Increase Contractility Shock algorithm directs –Dopamine –Dobutamine –Norepinephrine

29. Tx  Reduce Fluid Retention Diuretics –Lasix –Bumex

30. Acute Pulmonary Embolism Chemeketa Community College Paramedic Program

31. Acute Pulmonary Embolism

33. Defined  Blood clot lodged in pulmonary artery Blocks pulmonary artery flow Supplied area ceases to function Decreased gas exchange V/Q mismatch

34. Defined  Typically forms in deep veins of thighs  Can also be fat or air

35. History  Anticoagulation therapy Heparin – 1930s Streptokinase – 1930 Urokinase – 1951 1960s – Large study of clot resolution Recently TPA

36. Incidence  Unknown, range from 50,000-100,000/yr  Higher than diagnosed, most diagnosed postmortem  8% death rate with heparin tx  1/3 will die within 1 hour

37. Risk Factors  Deep vein thrombosis  Prolonged immobilization  Surgery  Trauma Pelvic or femur fractures  Late pregnancy

38. Risk Factors  Thrombophlebitis  Certain meds Oral contraceptives  Atrial fibrillation  Smoking  Unknown

39. Increasing Frequency  Older population Malignancies More sedentary Heart failure COPD Surgical procedures

40. Presentation  Variable and Non-specific Dyspnea Pleuritic chest pain Syncope Hemoptysis RHF Tachycardia

41. Presentation  No physical findings significantly accurate  Deep venous thrombosis in proximal lower ext. helpful for Dx Only about ½ source known

42. Why doesn’t lung tissue die from emboli like heart muscle?  Lung has two blood supplies Pulmonary and Bronchial Share capillary beds

43. Pre-hospital Treatment  Good Physical Exam and History  Index of suspicion  Airway  High flow O 2  IV  Rapid Transport

44. Treatment ???  Heparin  Thrombolytic agents Streptokinase TPA  Catheter fragmentation  Catheter embolectomy  Open-chest embolectomy

45. Definitive Diagnosis  ????  Angiographic  V/Q scan (venous/perfusion mismatch)  Operative  Multiple sources of evidence

46. Differential Diagnosis  Pneumonia  Herpes Zoster  Pleurisy  COPD  Rib fracture  Asthma  Angina  MI  Pneumothorax  Pancreatitis  Hepatitis  Salicylate OD  Bronchitis  Hyperventilation  Lung carcinoma  Sepsis  TB  Muscle pain  Costochondritis  CA  Pericarditis  CHF  Percardial tamponade

47. Watch Out  Extraordinarily difficult to diagnose  Watch out for hyperventilation  Young women

49. Group Projects! Work in Pairs and find the answers

50. List As Many Drugs As You Can That Will Dilate Blood Vessels.  Name the source  Describe why they work

51. List Drugs That Cause Tachycardias.  Describe why they cause increase rate change

52. List Drugs that cause Bradycardias.  Why do they cause them?

53. List Drugs that cause Hypertension.  How do they do it?

54. Your patient has a heart rate of 140 bpm. What could be his problem?