CMC/CSC Exam Review: Cardiac Assessment - MED-ED

welcome to methods third edition of a cardiac medical and cardiac surgical examination certification review my name is kami Fancher and I'm the presenter for the modules for this review course we've already done module one and two this is module three which is a pretty good review of cardiac assessment on both examinations there were questions about heart sounds physical assessment keys so this is actually a very important module and it goes over everything alright let's get started now where do you think you do your best assessments I do my best assessment standing in line at the grocery store and I look at people look at these people if one guy looks a little jaundiced you look at somebody's legs and say oh my gosh they have heart failure look at those legs this guy has COPD he's try potting you look at something go I could get an IV in that without a tourniquet we are nurses we always do assessments and we do them very well maybe not so much on our family members but we do them really good in public I have children at night when they were a little bit younger not so much now they're adults but I would say oh go around the other way and take that person's picture and they would say no mom I can't do that go yes a perfect specimen look at their the diabetic they have COPD we do assessments all the time your eyes are trained to see a lot of a lot of things a lot of things in a very short time when I walk into a patient's room I look at the I look at the monitor I look at the suction Canadore I look at what position they're in I look are they engage with me what color are they what temperature are they I look at all the equipment in the room and that's probably in the first second that you walk in so general assessment occurs very quickly essentials of the of the assessment are vital signs and remember those vital signs and one of the first chapters are modules we went over vital signs blood pressure heart rate respiratory rate and temperature don't forget the pulse pressure but really in the cardiac assessment it is really is there perfusion is the heart perfusing the heart well enough such as when I do a cardiac assessment I say is the patient warm and dry the skin is not a very high oxygen demand er so the first place that your blood flow is deviated away from when things are going wrong is a skin so if you're a warm and dry your perfusion must be ok because your skin is being perfused if you're awake and alert and you're meditating all right your brain is getting enough oxygen and glucose and if you're making urine so the things that I kind of look at is the patient awake and alert warm and dry making urine if all those things are real their perfusion is okay if something begins to alter we look at those three things now don't write this on your evaluation but I happen to love Foley's because I always want to know how much urine output the patient's making because that is a sign of general cardiac function now remember what we do for a living we always want to enhance oxygen delivery and decrease demand so we use our assessment tools to figure that out so a critical assessment is really observation and it also includes palpation percussion and auscultation a real physical exam now in my early years we did percuss the heart to see the borders of the heart we don't do that anymore we have x-rays we have echoes we have much more advanced equipment we don't do that but you do look at the patient you can palpate and you listen so you need good ears and the good stuff a scope to do this and you do it in a systematic order every time so when you develop your physical assessment skills you're going to do your physical assessment that's the same way each and every time so you don't forget apart or or get out of sequence cardiac function cardiac is it meeting and demands of the patient writing how to maximize their cardiac function and to protect the other organs the liver the lungs okay so inspection look feel what is the patient's smell like inspection overall appearance which fermentation are they awaken alert that's a good one their color their breathing pattern and their temperature the heart and lungs cannot be separated we always talk about cardiopulmonary function so we're not just assessing cardiac function when you listen to the heart you're going to hear the lungs somebody's breathe in 30 times a minute that's not right you have to figure out what's going on with the patient chest wall palpation and the patient really should be naked now if you want to be very specific and very exact when you're doing a patient's cardiac exam you should be on the right-hand side of the patient the patient's either on an exam table or in the bed you should be on the right side and the reason is you then have a tangible view you're not looking straight now at the chest but at an overview of the left chest where the heart is you can look for pulsations in a thin person you might see pulsations and then you would feel them and then you would listen to them so chest wall movement abnormalities what's your chest look like are they barrel-chested and somebody's barrel-chested you know you're not going to hear the heart way over here you're going to hear the heart and at the gastric area if they're concave if they're pigeon chest you know you're going to be able to look and then feel and then hear so first thing you're going to do is how the patient lay down be comfortable and feel with the flat part of your hand and you're gonna feel for any type of pulsation or rocking movement if somebody has by than tricular failure and they have an enlarged heart their big baggy you know right and left ventricle when you put your hand on their apex or where you think the apex is you might even see this we call that the rocking horse chest wall and that's indicative of right and left ventricular failure you may see that you may see it and then feel it in a normal person the PMI point of maximal impulse is very discrete you feel the heartbeat and it's just pinpoint so after you kind of feel with your hand you're going to decide with the top parts of your fingers when you use your hands for physical assessment and your fingertips are very good at feeling the size and exact location of something palm of your hand is not too not too sensitive if you're feeling temperature if you use the dorsal part of your hand because this is much more sensitive in this to temperature so I feel the point of maximal impulse and then I'm going to to listen right if I feel a thrill I know I'm going to hear a bruit which means a mama you feel thrill so it's easy to remember and you hear breweries so if I put my hand on someone's chest and I feel a vibration I know I'm going to hear a murmur and I want to I want to listen to where I felt that vibration was strongest so you feel a thrill and you hear a broody but I want to look at specific parts of the heart oh sorry specific parts of the heart so I look at the I look at these areas and I look at the aortic area pulmonic a order can pull moderate apical and epigastric and I'm going to listen with the diaphragm so here's the air it is to the right of the sternum is the aortic to the left of the sternum is the pulmonic and then I don't really look at that third space inter and the third intercostal space I go right to the right ventricle that apical and then the epigastric so I'm going to feel in all these areas and that's also where I'm going to listen and I'm going to listen with the Bell of my stethoscope and not and the diaphragm of my stethoscope my auscultation it's something people always ask me cami teach me heart sounds you know what it's very difficult to teach heart sounds the best way for you to learn heart sounds is a get a good set of scope and listen to all your patients go look at the progress and see what kind of murmurs they have sometimes you you don't hear it sometimes you do murmurs do change with the hemodynamics of the patients the way they're sitting there they're standing or their volume status right so when your users the scope in those five areas you're going to listen to rate rhythm you know listen to s1 and s2 and see if you hear any other heart sounds if you work in the ICU or in the step-down unit where you have a monitor right there it's easier to discern s1 that's the air itself opening because the heart is squeezing that's the beginning of systole you see a QRS and then you see diastole so you can hear it you can kind of pinpoint s1 and s2 and listen for extra sounds so listen in order first and second heart sound this patient's laying down comfortable this is my friend TJ she's a nurse practitioner of cardiac nurse practitioner and she's listened to the aortic the pulmonic and that the right ventricle now she's looking right at the apical impulse and she's listening as someone has to looking at the timing you can even feel the carotid if you don't have a monitor to feel for the timing now if you think you hear a momma or you think you hear something in extra hard sound you can change the position of your patient if you sit up and lean forward in some patients that's going to bring the heart closer to the chest wall alrighty so this is a technique for listening and so I'm going to move the patient over leaning over exhale completely and hold their breath if they can it accentuates aortic murmurs so it works to notice you'll hear very well in this position the other position and I want everybody to do this is your homework for tonight when you go to bed tonight I want you to lay on your back and put your hand over where you think that apex of your heart is you'll probably aren't going to feel anything maybe a little tiny tapping but then I want you to roll over on your left side put your left arm under your head put your right arm down by your side and lean over just a little bit lean forward and put your hand under there and you will feel your left ventricle beating up against your ribcage and you'll be able to discern it very discretely so roll the patient over this also accentuates s 3 s and s fours mitral mama especially mitral stenosis okay very very well in this position so it's always about location location location now this is a very important slide righty there are several especially on the cardiac medical there are questions about heart sounds cardiac still has one or two cardiac Medical has a few more so let's look at this slide together as you're looking at the slide right in front of you the first big line is s1 already s1 is the aortic valve opening mitral valve closing this is very easy to remember the left ventricle is filled and now it's going to contract we're starting systole so it's going to contract if your ventricle contracts the door has to open the aortic valve has to open and get blood out the aorta then you have the ejection then you have s to the or table closes some mitral valve opens and now you begin diastole diastole is always longer than Sicily if we have perfect sinus rhythm in the 70s you have one third systole two thirds diastole and that's why when you're looking at mean arterial pressures it's not systole plus diastole / - that would be an average it's a mean it's systole plus 2 times diastole divided by 3 that's how you get a mean arterial pressure so diastole is longer why the ventricle is filling and the a will and the coronary arteries are filling so let's look at this a little bit more carefully if you look at s the S one you see that little line above it that's the end of diastole s one is the beginning of Sicily so ad is the heart all the valves are closed and the heart is resting at the very end of diastole the pressure in the left atrium is about 10 the left ventricle about 10 at the end of diastole and the pressure in the aorta is 80 so I can't get blood from a pressure of 10 into a pressure of 80 I can't do that I'm going against a gradient so the first thing that happens in Sicily with all the mouth closed the aortic valve and the mitral valve are closed is the ventricle begins to contract that's isovolumetric contraction that is when the heart is using the most oxygen and the most work because what it has to do they generate a pressure greater than 80 so you can pop open that aortic valve and slam blood out and get ejection so first you have ISIL volumetric contraction and then you have ejection that's when your heart is really working open up that AAA yourself now the a where it's out closest a mitral valve opens and now the the ventricle is filling during systole remember that your heart does not eject every CC of blood only about 60% so if there was a hundred cc's in your metrical 60 CCS went out and over in that diastolic period there's a little bit of blood left in your ventricle your ventricle never wants to be empty if it empties the patient river leaves you know people died of exsanguination they bleed out and their hearts fibrillating then they died I have no perfusion so 60% reduction fraction so you have a little bit of blood left in that left ventricle so no now let's talk about diastole in early diastole the mitral valve opens and the blood that was in the atrium just falls into the ventricle we call that passive fill and you don't hear that sound you don't hear that noise at all at all at the end of diastole in normal sinus rhythm the atria contracts and pushes more blood into the ventricle that's and diastolic filling right that's when that's when you have the ventricle at end diastole after the atria has contracted and so we talked we used to call that atrial kick remember atrial kick and now we just call it fulfilling that is how your ventricle gets filled all righty so that's how it works now how we look at heart sounds we're talking about s 3 and s 4 and where they occur and where they occur well let me go back for a second let's talk about s 3 and s 4 and s 3 s 3 s and s fours are always always pathological and the adult remember when we talking about adults showing s 3 FS 1 systole s 2 diastole occurs very early right after the s 2 and what happens in a patient who is in heart failure you know they have a 10% ejection fraction their ventricle is full 100 CC's it squeezes only 10 cc's goes out so it early diastole that ventricle still full when the mitral valve opens and blood falls in early very early and I Slee now it's going to cause turbulent blood flow and you're going to hear it you're in hearing s3 it always tells you that the patient is volume overloaded right es3 always volume overloaded now let's talk about that s4 again it's always pathological and it happens at the very end of diastole end of diastole and it happens right before s1 now what happens here is remember that an early diastole blood just Falls from the atrium to the ventricle and we shouldn't hear that my spacers are overloaded and at the end of diastole when that atrial contraction occurs and pushes more blood into the ventricle we should call that a chole kick now we just call it preload the amount of volume and that ventricle at the end of diastole if the ventricle is very stiff patient had long term hypertension they have aortic stenosis for a long time and that ventricle is thick and stiff now in that atria contracts it has to pump me really hard to push that blood into that stiff ventricle non-compliant ventricle you make turbulent blood flow in here and s4 so you will hear a chronic us for in anybody lessee or x10 osis or a long term hypertension acutely acutely what can happen I make it here in s4 is an acute STEMI once that area of the myocardium has infarcted that part of the heart becomes stiff so you may hear acutely an s4 with a STEMI all right we have chronic and acute okay so as fees and escorts are always pathological s3 volume overload s4 are non-compliant left ventricle good good now murmurs we talk about murmurs in timing diastole or almost distally systolic murmurs diastolic murmurs location of where you hear at the best and does it transmit does it transmit up to the carotid does it go back Scylla where does it go so systolic murmurs are a or texts enosis very big when you'll hear that a lot mitral regurgitation and you can hear that a lot or a VSD or ruptured papillary muscle and here's where they'd like to ask you a question they'll say you have admitted a patient with an anterior septal wall infarction they're doing well but all of a sudden the patient's heart rate goes up they complained of shortness of breath they look like they're going into a cute pulmonary edema and you hear a loud systolic murmur that's a ruptured papillary muscle and the keys are stuck the wall on farken infarction which means a peppering muscle two to three days later ruptures and you have a cute mitral regurgitation and you hear this loud murmur not remember okay that's a classic thing on the exam and that's a classic thing because now we have to pick it up call the doctor if that patient needs to go to the or we can put a balloon pump in we can do a lot of different things too to have a time delay but the real key of that is the mitral valve repair diastolic murmurs or mitral stenosis and aortic regurgitation and a lot of people have mixed but this is where you hear the mitral stenosis which is a big one an aortic regurgitation all right so here's what you see now this is just a phonogram of where you see the murmurs so normal s1 s2 my aortic stenosis that's just a Stalag murmur my children GERD little murmur now that a or stenosis is a crescendo decrescendo it looks like a bell see here and it tapers off now it's only during systole what's a very short time it would be nice if the patient at a heart rate of 60 so you can hear it sometimes if their heart rates 120 very hard to hear a or decree girge long diastolic murmur a PDA a patent ductus arteriosus is you here at awethu systole and diastole Oh systolic mama they ordered stenosis you hear all the way through writing so those are the one you really need to know a Gordon stenosis and mitral stenosis and mitral regurg but if you know that one slide where s1 and s2 in North Sicily as you know where diastole is you can tell where the murmurs occur and where you were hear them this is how we grade murmurs and this happened a long time ago and I used to say a grade one murmur is one cardiologist out of six hears it it's very faint I've had really good ears a six over six and you're standing at the foot of the bed and you hear the mama in the old days we need to get people with really bad rheumatic heart disease and they would have all of their valves would be insufficient and you would stand the foot of the bed and it sounded like a washing machine you're all systole and all diastole you could stand the foot bed you do still see that in developing countries where people don't get strep throat you know identification and treatment but here we don't usually see that as much as we did four years ago years ago so what sound to you here is it new so this can confuse you sometimes because say you have a medical patient being admitted there's no bezel MICU and you're meeting a patient from the easy with pneumonia and he has COPD so he has high pulmonary pressures riding and now he has pneumonia which means the pulmonary pressures go higher so that puts a big after lid on the right heart the right heart dilates and now you hear they tricuspid regurge mama when the pneumonia goes away and systolic murmur when the when pneumonia goes away and the PA pressures come down that moment goes away so sometimes disease states can accentuate murmurs because we're changing the hemodynamics of the lung Emma and the heart so sometimes you see that on the test of what you really need to know is that acute mitral regurgitation that's a big one and are there any other changes in the patient's physical examination the arterial system we're always feeling for pulses and we all know that if you have a radial pulse you should have a brachial and maxilla so I would just go for the break oh you also know that for a good peripheral arterial exam you have to do both extremities and you compare one extremity to the other not your extremities the patient's extremities so if I have a 2 plus radial pulse here I should have a 2 pulse radial pulse here my T if this hand is warm this hand should Norman I use them as the but constant so the arterial system inspection palpation rate and rhythm amplitude and contour and blood pressure using the correct blood pressure cuff that's the hardest thing for me sometimes we do have some obese patients and I can never find those great big cuffs for those patients looking in arterial waveforms there there are no waveforms for you to analyze on the exam but number one is normal weak pulse bounding pulse 5friends pulses means you have like two dichotic notches pulses alternans this is the one I want you to pay attention to this is not a patient that's having PA sees or just written as they are in sinus rhythm completely normal rate and rhythm but you have a bounding pulse this is arterial pulse a bounding pulse and then a weak bounding week dauntingly that is a very early sign of heart failure or left and tricular dysfunction you may see that in your heart failure patients if they if you're lucky enough to have an arterial line a very early sign of heart failure by geminal pulse that's because of P ACS but look at the bottom and that's another one that's very important paroxysmal pulse which swings with inhalation and exhalation when you and I breathe our blood pressure changes a little bit but if I take a really big deep breath in and I increase my pulmonary pressures I we decrease venous return and my systolic blood pressure should drop a little bit but not much maybe by five nine years of murmuring maybe six but if I have swings of more than 10 millimeters of mercury between inhalation exhalation it means I'm paradoxical it usually means it can mean that I'm in Traverse really dry or that I have very high pulmonary pressures very high Clemenza patient with a pulmonary embolus might have that a patient with bad pneumonia hi PA pressures you may see that a patient is hemodynamically unstable because their volume deficient you may see a paradoxical pulse now remember this not the EKG this arterial line pulse this is arterial flow you have a radial and a brachial artery and because your palm your palmar arch has two distinct arterial blood flows the owner and the radio so before you put an arterial line in anyone you're supposed to do an a lens test to make sure that the owner can still feed the hand and the old way of doing that is to have to compress both arteries let go of the ulnar and look at the color change in the hand but that is very subjective are they pink or they wait how many seconds does it take it's very subjective so a modified artery allons test is to put a pulse ox on the thumb thumb has bilateral both arterial blood supplies put a pulse ox you have a pulse of 70 and 100 percent saturated you compress the right of the ulnar and the radio compress if you get zero let go of the owner keep the radio and what should happen within a second you should get rate and 100% pulse ox so now you can say return to flow in one second 100% 100% that's pretty scientific pretty good so I feel comfortable putting a radial artery line in the patient so so arterial perfusion now I know nobody does this anymore for looking at jvd and measuring jugular venous distention we just don't do it anymore we do echos if we have any question about the heart we do an echo gives us really good information about structure and function of the heart and great vessels but if you're going to look at jugular venous distention you measure it from from this angle and you look at it it's hard to see here but this gentleman does not have any jvd he's a 45 degrees you and I would not have any jugular vein distension we wouldn't even see the jugular vein so if you're going to look at the jugular vein it's very palpable you can't feel it's not an artery it undulates it has an AC and V wave just like your CVP it is a measurement of the CVP right it eliminated by pressure so if I put my finger lower I could obliterate the whole thing and the level of the pulse inspiration it may change may go up and down it varies with position if you stand straight up so your carotid however should be palpable it's one component you can't eliminate it it's unchanged hopefully you feel the carotid when the patient is sitting up and laying down so those are the differences between the two and we sometimes look to see if the JV is is distended or not our heart failure specialist still use this is a very good time to see about volume but I'm going to give you a question mark here if somebody has high pulmonary pressures or they have right ventricular failure but their left ventricle is normal what will the CVP be normal left heart on a cute right ventricular failure the CVP will be very high because as the right ventricle fails that pressure and that right ventricle goes up and the same the pressure has got to go up during diastole the pressure is going to go up in the right atrium and and the jugular vein so your CVP is going to be elevated it does not always tell you what's happening on the left side if they have just right ventricular failure you have no idea what the volume size is on the left if you have by ventricular failure the CVP says it was 15 your volume overload all right be very careful about that CVP now if the patients at 45 degrees and you're looking at the jugular vein and it appears to be distended and you have a heart failure patient and you push up on the liver if that patient has liver congestion the jugular vein will get worse the jvd will get worse that's the peddle jugular reflux and we see that often and right ventricular failure patients right in there you go pressing up on the liver looking at the GV now what you see in this gentleman laying down is not as jugular vein that's his internal jugular this is external jugular vein all right peripheral evaluations you're going to look at venous and arterial perfusion you look at the legs they have a shock start now be very careful because a lot of athletes that were really tight athletic socks may shave their legs or may have very poor hair just distribution where their socks are it's not an example of arterial insufficiency all right look for varicose veins venous stasis the patient sitting down their legs are purple you put them up and they turn pink venous stasis older age female overweight inactivity smoking has a big deal with things as arteries and family history swelling a lot of different things can cause leg swelling it's not always heart failure and you'll be salt abnormalities thyroid abnormalities me my legs are so long at the end of the day after working 15 16 hours because I'm old I have great arterial perfusion and I don't even have varicosities but when you're standing up for eight hours and drink a diet coke all day long your legs swell a little bit so look at the peripheral evaluation this is looking at varicose veins you see a normal vein with valves right so it keeps blood going in this good direction and here you have incompetent valves and a distended almost in your original white mane which can cause a lot of pressure discomfort for the patient get more index of suspicion of having blood clots in your legs right there's a great example on the right there you see a normal leg on the left horrible varicose now sometimes today you don't see that because we do we don't do vein stripping anymore but they can inject or do laser and get rid of those but you know one day you might need your staff in this vein so be careful be very careful with that now here's an example two different patients with horrible heart failure and the one on the right because it's so red looks like so your latest but what it is is the one on the left is brawny is Brown from having continuous venous stasis and swelling in their legs actually changes the color of the skin the one on the right is again this is more acute venous stasis with no cellulitis whatsoever and it's red on both sides with the brown spots but both are swollen for a while so cardiovascular exam what did you find did you see inspection palpation auscultation what did you find and put it all together does the patient look like they have heart failure do they look like they have arterial or venous insufficiency and remember are they awake and alert as their skin warm and dry and I'm making urine those are really the essentials of a cardiac examination and you put it together for the exams they're going to go more into the hemodynamics and the heart sounds heart sounds will be very important for the examination now let's talk about hemodynamics many of you may never have seen a PA catheter even used if you work and you know in the cath lab if you you know hemodynamics of course but when you get to the ICU or the step-down you don't have a PA catheter both exams have questions about PA catheters and the movement of blood through the through the great chambers hemodynamics that word means the movement of blood through the heart the chambers of the heart and the great vessels and what why would we use this well a lot of people don't use a PA Catharine more because you have to do a central line stick and you have to understand the waveforms you have to understand the meaning of the waveforms but why we use it is not just for the pressures within the heart you can get samples but or cardiac pacing but for the use of the delivery of oxygen and the use with a PA catheter was the first time in the 70s that we could measure how much oxygen we deliver and how much is being demanded by the heart and the great vessels so so there are a lot of pros and cons to using it we're just going to go over it because it's gonna be on your examination many hospitals don't use them at all many mi C's don't use them at all the patients that may have PA catheters or you're very sick high acuity cardiac surgery patients a simple bypass surgery that patient may come out and only have a triple lumen no PA catheter all right but if they have a very poor ventricle if we're doing ventricular protection or heart protection cardiopulmonary bypass protection of this patient they are at great risk for induction for surgery for having a STEMI or non-stemi that will put PA catheters in and monitor more carefully so there's your numbers numbers that you need to know and so let's put in a PA catheter we're going to go in through the right IJ and put this PA catheter into the right atrium and a couple of things in the next couple of slides I'm going to talk a lot a lot about heart failure because that's on the exam the key to remember is that in embryology when you were developing your heart was a muscular tube it was just a tube and then through embryo a food through your development as an embryo into a fetus that muscle turned and twisted into four chambers and your great vessels but blood enters one and comes out the other blood all goes in one direction there is really no such thing as backward flow if the right ventricle fails the pressure gets high blood doesn't flow backward but is very difficult for the atrium to pump blood that way so that pressure has to get higher and this pressure gets higher and that pressure gets higher if you have backward blood flow if blood is going from your left ventricle to your left atrium you're dead you've got to have blood going in a forward manner or you have anything coming out into the aorta and the patient would die so it's not a matter of backward flow it's a matter of the pressures changing and difficulty of forward flow or poor forward flow so let's go into the right atrium go to the right atrium like your CVP and normal radiate your pressures about five millimeters of mercury it's very low when you're at work maybe it's one you don't drink you know you don't drink enough water get dehydrate that's five millimeters of mercury who's ever putting it in it's going to ask you to blow up the balloon and from the right atrium it floats into the army but I want you to look at that picture the pulmonic valve is closed and that tricuspid valve is open look at the right side it's white right atrium right ventricle the tricuspid valve is open the heart is in diastole pulmonic valve closed so the right atrium and the right ventricle are communicating blood flow is communicating so it is and diastole the same pressure so I have five millimeters of mercury in the right atrium and the right ventricle the diastolic pressure is five but then the tricuspid valve closes and the right ventricle contracts and now it's a now you have a bigger systolic pressure so that the pressure and the right ventricle is about twenty five over five that's very important okay 25 over five if I have a cute white ventricular failure and it goes to 35 over 15 what's my right atrial pressure me what's my CVP gonna be it's going to be 15 whatever the diastolic is in the ventricle is going to be the pressure and the atrium so if it's 30 over 10 my CVP will be 10 if it's 45 over 20 my CVP is going to be 20 it has to because that atrium has got to pump blood to the ventricle to the pulmonary arteries to the left side of the heart it has to go that way so five twenty-five over five and now that right ventricle is pumping blood through the plum onic valve into the pulmonary artery and the normal pulmonary artery pressure is 25 or ten a little higher diastolic pressure it's not communicate that mitral valve that pulmonic valve is closed so 25 over 10 is the most normal pulmonary artery pressure that's important what is that number tell me it tells me the pressure inside the lung parenchyma where the alveolus is in the capillary bed the pressure in the lung normal you've never smoked before you don't have asthma you don't have pneumonia you're not hypoxic you don't have anything wrong with you the pressure inside your lung is 25 over 10 now what makes the pressure go up well if you have COPD asthma chronic emphysema chronic bronchitis because there's there's destruction of tissue in your lung and it makes your lung stiff anything that makes anything in your body stiff the pressure has to go up so the pressures go up so COPD asthma you may have never smoked but you have asthma you might have pulmonary hypertension heart failure might would cause pulmonary hypertension because you have fluid in your lung pneumonia causes pulmonary hypertension hypoxemia so when your patient becomes hypoxic or if I take you to the Plano Alta which is 20,000 feet there's no oxygen there your pulmonary arteries and pulmonary veins are going to vasoconstrict and your pulmonary pressures can go way high that's how I can get flash pulmonary edema from altitude right so those are all things that make it go up and a pulmonary embolus big one pulmonary embolus all right so you've never smoked your pulmonary pressures your right-sided pressures are on normal you have a lot you get off an airplane you have a large pulmonary embolus your pea pressures go up really fast the right heart dilates and fails and you look very sick when you've got your very hot box so you met you can't breathe you're starting to turn funny colors you might you have dysrhythmias right from pulling an embolus what makes the pressures go down in the pulmonary artery are things like your bleeding your exsanguinated or the right heart is failing if the right art can't pump blood into the pulmonary artery you're not going to have pressure so now let's wedge the catheter so at the tip of that catheter is a balloon the tip of the catheter is a balloon and so what it will do is you're in the main pulmonary artery it'll wedge and one of those little smaller pulmonary arteries which means that the balloon is inflated and the tip of the catheter which senses that pressure is looking that way and everything this way is occluded from the catheter so in essence the wedge the wedge pressure which is going to be always lower than the PA deep Emeritus Daleks SB less than 10 8 9 could be 10 but it should be 8 or 9 even 6 are your wedge pressure tells you the filling pressure at the left side because from that pulmonic valve and trace it all the way down the pulmonary artery all the way pulmonary capillary all the way pulmonary vein all the way back to the left atrium there are no valves it's a continuous circuit so when I'm looking down there I'm seeing the pressure the pulmonary artery pulmonary capillary pulmonary vein left atrium so the wedge pressure gives me an indirect reflection of left atrial pressure so let's have a very special catheter it's called a cami catheter we're going to snake it all the way through the lung into the left atrium what's the pressure in the left atrium 4010 left atrial pressure is very low it's very much like the the right atrium a little bit a little bit lower a little bit lower for maybe 210 and now put that catheter in the left ventricle because isn't that what we want to know we want to know less intuitive function left ventricular filling how's that left ventricle working what's the volume status a little left ventricle left and tricular pressure is now you have to be careful remember that mitral valve look at that look at the slide just slide in front of you and that shaded in area left atrium left ventricle that mitral valve is open so whatever pressure is in the atrium is going to be in the ventricle so if my pressure in the atrium is 5 my left and tricular pressure is 120 over five now in general the left atrial pressure is usually around ten and your left ventricular pressure is 120 over 10 L ve e P left ventricular end diastolic pressure is 10 all right so if I have a wedge of 10 I know that I'm good if I have a wedge of 25 I know I'm in heart so left ventricles over overfilled if I have a wedge pressure of 1 I know I'm not getting enough blood flow to the left ventricle the PA only tells me about the lung the wedge tells me about the filling pressure of the left side dr. Swann and dr. Gant's were brilliant when they figured this out and was 70 s my name because we had no way to measure what was over there we didn't have ultrasound we had echo but you had to have an echo check come with echo machine and we couldn't even do that under Stephanie's at the bedside all the time all the time so this is a mechanism to look at pulmonary pressures and filling pressures on the left side so let's take it more and look like a tube when you look at this slide you have the right ventricle on on your left side there's the right ventricle a pulmonary artery to the lung pulmonary vein to the left ventricle and then your arterial system on the bottom that's the capillary bed so remember the whole idea of having a PA catheter was to have something where we could measure the delivery of oxygen and the consumption of oxygen so if I wanted to measure what oxygen I'm delivering I would do an arterial blood gas but what I would look at is I don't want to look at the pao2 I want to look at the arterial direct saturations not your pulse ox I want to look at the direct arterial saturations of oxygen so that should be 100% so I'm delivering 100% every single one of my hemoglobin has oxygen on it and I deliver it to the cells the cells you utilize it vo to demand utilizes that oxygen as much as it needs then the venous brings it back to the heart the heart dumps out its Phoenix blood and the bottom of the right atrium and then I measure the venous blood in the pulmonary artery the pulmonary artery is the only artery in the body that has Nina's blood and that blood has gone to every cell your brain sell your kidney sell your big toe so and dumped off the oxygen that was required so a fine measure that svo2 true mixed venous oxygen Asian it tells me how much the body is demanding in normal people if I measure the svo2 it's 70% Stephanie which means my body in normal use working is only using 30% of my available oxygen I have a reservoir so that's when you're doing CPR you really worry about fast and furious CPR 120 beats per minute 2 inches down to pump the blood around because it's well oxygenated at least for 6 minutes after 6 minutes you have to replace that oxygen it'll be used so that's very good if you do not have a PA catheter but you have a PICC line or you have a triple lumen in the right atrium that's no longer svo2 it's not true mixed venous it's as C central oxygenation and now we're looking higher we're going to subtract the venous blood from the heart and so now it's going to be 75% so in your PA it's 70 and your right atrium is 75% which is very close very close so we have an way now to monitor oxygen delivery and oxygen consumption and remember that's all about critical care delivery and consumption so when you look at svo2 or an SCV o2 what you're really just discovering is what's a cardiac output what's the 18h if your ACH is low it's going to be low Marty if you can't oxygenate the patient your sto truth will be low and you're looking at the metabolic come in hand how much so we learn in the 70s when the patient's of fever what happens their f-feel Jews will they plummet when they're in pain when they have a grand mal seizure they plummet because your body becomes hypermetabolic can you use up all that oxygen right so we don't want people in pain you don't want them to have fever you don't want them to shiver you want to control their environment as much as possible so we can deliver and decrease demand perfect perfect here's again your humo dynamics those are just the numbers that we that we use but here's another thing to remember there's a lungs at the top there's a tunnel and there's your train coming out of the tunnel on the right side is your hemoglobin and each hemoglobin is completely saturated with him with oxygen so you know 100% saturated your pump the purpose of the heart is the drive hemoglobin to the cell and the pH is normal the glucose is normal the hemoglobin is normal and so as it goes through the tissue demand it always gon take 30% out 25 to 30% here it looks like 25% one hemoglobin was gone oxygen was gone three are still loaded so 25 to 30% it's a perfect system when everything the heart and lungs are working right it's when people are sick that we need to pay attention to this and optimize the patient as much as possible on the surgery exam there are many questions about these are your parameters this is your hemodynamic profile what would you do we're going to wean something you're gonna give them fluid you're gonna start another drug that's the diagnostic and monitoring part and those are very good questions now let's just go over the EKG and there are a lots of questions about 12-lead EKG s on the exam they don't give you a 12-lead to look at but there are multiple questions in general the EKG gives you just you know a very brief period of time of the electrical activity of the heart in a very brief time how long has it take to do an EKG five seconds so that's all we're seeing that's why we can do a lot of repeated so we can look at rhythms get a better idea about rhythms if you don't know if the patient's really in v-tach e of 12 ly look at your me leaves look at a vr maybe decide whether this is really the attack or it's just a parent lis conducted conduction defects electrolytes now you and I was especially if you work in the ICU I'm not going to wait for an EKG change to figure out whether I need to do a potassium or not just understand potassium but you have to know the changes that occur on the 12-lead for that drug toxicities especially like did chamber enlargement hypertrophy you see different changes in the amplitude of the EKG and the most important thing for you and I is myocardial injury ischemia and infarction so we're going to do a 12-lead it tells us about the pump meeting the demands it really only tells us about the electrical function and has doesn't give you any idea about ejection fraction all right now 12-lead it's just the recording okay and this is the normal 12v the P the Q the P P R interval the QRS and remember not every QRS is a QRS could be just an RS SP T wait T wave is always asymmetrical if the QRS is positive the T wave should be positive and not everybody has a you wave the you a there's really designated we learn about this from dr. Marriott that it is a process of when the ventricle repolarizes and so sometimes when the patient has a QT that's being prolong you see that you wave and we see that the patient may have reentrant dysrhythmias but at that time so that's normal there's an ST segment the T wave right look at that ST segment carefully if it's above the baseline below the baseline CF ST segment elevation and depression whereas a J point here's where we put our leads you know the B leads money sometimes we do 15:18 the EKGs where we move those leaves to the to the right side to look for right ventricular dysfunction and then we have the frontal plane leads a br AVL lv 1 2 3 right those are very important and I think the most important thing I can tell you if you're not good with 12 lead the way to pass this test is to remember three things we have to remember just as three things one is ST depression equals ischemia ST elevation is what we call current of injury or infarction right and 2/3 and AVF those leaves two or three and AVF are your only inferior leave all the other leaves are interior if you can remember those three things any question you have about a 12-lead you'll get right get right for example they say your patient has ST segment depression on two three and AVF I see depression is ischemia two three and ATF is inferior inferior ischemia St elevation two three ATF inferior infarction right so the way that it the atrium depolarizes is from right to left starts in the SA node goes all the way through Bachmann's bundles and then down to the AV node writing and then here's how your normal ventricle depolarizes look at the picture on the left it goes through the septum from left to right so the right is going to contract just before the left the left is thicker it takes more time for the electrical current to get through it so you have right ventricular contraction then left that's normal that's normal so when we talk about resynchronization pacing the ventricles so they resynchronize it's not like this it's like this right before left and the new biventricular pacemaker x' do that for the patient in heart failure so in the picture on the left it shows you why in v1 you have to have an R wave and it's very important if you lose our wave in in v1 that means you lost septal activation that's showing you septal on electricity and the one you see there in v6 you see a Q wave that's because the wave of depolarization is actually going away so those are the kinds of things you see on that 12-lead EKG the first thing you're going to see and this is very important the first thing that you're going to see if you're worried about myocardial ischemia is a tented T wave t way remember is asymmetrical and rounded now first thing you're going to see is a tented T wave maybe in two and three 180 lb 1 & 2 so you see attempted t way the first thing you should think of and just facing leads is ischemia if you see attempted T wave and every lead that's a potassium problem so the first thing that scheming is attempted T wave and then you might see an inverted T wave again ischemia ST elevation in the middle picture there FC elevation current of injury and farken and then maybe the patient will develop acuity but not all people develop Q waves when they have a myocardial infarction only some do miss he'll get so hyper QT wave 10 to T wave t-wave inversion as the elevation and Q wave formation is what we call the evolution of EKG changes but you know not everybody read the book before they come in and not all patients do that so when you're 12 milli kg we were 12 that's our basic one if you think the patient's having a right ventricular infarction or something else is going on you can do a 15 or 18 lead EKG we've even done 25 VT kgs we wrap electrodes all around the whole back and everything looking for electrical abnormalities remember you're only looking for 5 to 10 seconds here and they they're not ischemic now but they were people have stuttering ischemia so you're always repeating the 12-week now here's where we get into electrolytes if the patient has an electrolyte abnormality you're gonna see it on all 12 leaves just remember that that's the best thing I can tell you electrolyte abnormalities in fact every lead hypokalemia for us in cardiac cardiac surgery or cardiology this is a big deal because hypokalemia induces ventricular irritability PVCs ventricular tachycardia so we don't want anybody's K to be lessened really 4.2 sometimes righty so what you see on the 12 we look at the top line there the 12 meet the first one that says the K is 2.8 that actually is a little bit low but you still have an upright T wave as the potassium goes down it gets low the T wave gets flattened so it's easy to remember low potassium low t-wave it's going to get very flattened and then you're going to start to see the development of a you wave remember that's telling that the QT interval is prolonging and you have the chance of having reintroduce with Mia's so what are you going to do for hypokalemia you're going to fix it oops by giving the patient potassium but now just remember in hypokalemia if they don't have a central line how much potassium can you put in a little peripheral only 10 per hour and maybe not even that because the patient is painful you can always give up to 60 any cues of potassium my mouth now I know you realize this before you've seen it clinical practice that when you give potassium by mouth it affects serum potassium much faster than IV why because you're giving more and to potassium is a weak acid and it's absorbed readily right through the stomach lining right into the bloodstream it doesn't have to go to the intestine be absorbed go to the liver be metabolized it gets right into your bloodstream as long as the patient on the vomit when you give them that potassium because it tastes so bad give them pee oh it works very well very well now hyperkalemia but testing was too high what do you see look at the bottom line there and you're going to start to see that example of a tented teewe t-waves should be asymmetrical and rounded this now becomes very symmetrical and looks like a tent or hyperacute teewe if you see that in all 12 leaves you know it's a potassium problem you need to send the potassium and when it gets high we have to fix it so say you call me and say kami the patient mr. Smith has a potassium of 5.5 I go well I have a sense of humor sir Oscar don't give any more potassium and we got to get rid of it so let's give the patient 20 of lasix IV 20 milligrams of lasix IV and they'll pee it out but what's the number-one reason your patients have hyperkalemia they've gone in to exactly they've gone into renal failure and you give them 20 of lasix and two hours later you take the potassium again now at 6.5 and your communes take I mean that was very successful patient P 12 cc's of urine and now they're there the testing of 6.5 I have to do something and here is sort of all the rhythm for hyperkalemia if it's about five five to six 6.5 you can give kayexalate animals usually two because that KX thing anima is going to pull the K out of the blood and into the rectum and the poop and they're going to poop it out so that's good they're going to get the K out all right but that's only going to last for a few hours because patient still has we don't feel your K is still going to come out of cell because a patient has real good the second thing we can do is the little bicarb the d50 and at the d50 10 of regular insulin and some amount of bicarb and calcium chloride so the last day I work I had a patient who went into a cubicle failure they call me but Tessa was 7.5 so I gave her one amp of d50 the reason I gave her that so I'm going to give her ten of regular insulin IV push 10 units so if I did like d50 blood sugar is gonna go up so I'll protect her from hypo King hypoglycemia but the ten of regular incident is going to drive the potassium back into the cell I'm going to give some amount and I gave this lady 25 any cues of bicarb that also shows the K back in the cell so let's the insulin the bicarb that do the movement the d50 is protective but what does the calcium do I'm going to give the patient X amount of maybe 500 milligrams of calcium IV calcium port what does that do it doesn't do anything for potassium it doesn't change your sodium potassium pump but when you do change the sodium potassium pump now the cells are unprotected and now you don't have good contractility so calcium protects the cell membrane and allows for good cardiac contractility so you're protecting the heart of the calcium I mean the patient's going to need dialysis if they're in renal failure but you know you can't get dialysis that even if you're married to the nephrologist it's not that within an hour so we'll do these other short-lived the K actually and the testing and bicarb that last maybe four hours and that comes back again because there still is still going to leak out the potassium so hyper killing me let me protect the heart hypocalcemia now hypocalcemia you know is going to change the QT interval and so it can precipitate torsades but if you see anything on the test about torsades what's the answer going to be magnesium so if you're a hypocalcemic you know i'm going to have good contraction you're not gonna be a good blood clot and you may have torsades hypercalcemia can cause a Sisley so look at calcium and then look at magnesium holy moly they look the same so they're never going to ask you which one is which but calcium and magnesium can lead to torsades but this is what i want you to remember about torsades to call the doctor and say that his patient or her patient has torsades this is what you have to have you have to have a prolonged QT interval whatever rhythm they were in before they had to have a prolonged QT interval and then they have a pause whatever rhythm there and they have a pause and then they go right into torsades you know alternating qrs's alright that's torsades this is not toward your patients in normal sinus rhythm no QTc interval prolongation at all they have an early beat they have a PVC and then they go into tour what looks like torsades that's um a very irregular ventricular tachycardia it could be called oh gosh what's ending for that I'll have to think about by name and get back to but there's a different name for that it is called can we pause it here oh my god was right now let's look at calcium you know calcium does a variety of different things for your your clotting factors and heart function like we talked about before but here hypocalcemia can cause torsades now of course if you see anything question about just your thoughts on the exam the answer is magnesium but magnesium and calcium look the same they make changes in the QTC alrighty so now prolonged QTc and then you're going to have malignant dysrhythmias so hypocalcemia can cost your size hypercalcemia can cause asystole so when you go to the next slide and you look at magnesium they look exactly alike but a couple of things I want you to remember about torsades to really make the definition or the diagnosis of Prasad's the patient had to have had a prolonged QTc and whatever rhythm they were in before and then what happens if you see a pause and then they go into torsades you know turning of the points matriculate type of cardio that's torsades if you saw this the patient had a rhythm no prolongation of their QT c they have a PVC a premature B and then go right into turning of the points that's variant ventricular tachycardia that is not we don't treat that actually with magnesium we treat with lidocaine actually so just keep that in mind that there are different types of turning of the points variant or actual torsades torsades is treated with magnesium hypermagnesemia like you see with renal failure can cause asystole so again these are just the assessment tools that we use so your regular assessment inspection palpation auscultation auscultation is very important and you are going to have some very good questions especially about mitral maker acute mitral regurgitation and that patient acute MI you might have other murmurs and definitely s3s and s4 so those are thing you really need to be able to talk about and then with a with a PA catheter especially in the surgical there's a lot of questions about PA catheters your patient as a cardiac index of 1.7 they'll give you some parameters and what are you going to do to fix that make that cardiac output better in the cardiac medical they'll ask you much about medications and cardiac output and how are you gonna make that better and how you're going to assess how can you lean that epi drip or that melanin drip if you're not looking at some parameter and then the other types of assessment tools that we have there are not too many questions about echocardiography or ultrasound although that's the way we really do everything in the critical care area today if you if you're interested in echocardiography or ultrasound and i see you now we use ultrasound for everything just go to youtube go to youtube and look put in normal for chamber view of echo or ultrasound and they will show you a real-time film of the atria and the ventricles and what they look like when they're normal so the next time your intensive ministry or cardiologist comes by and they bring the ultrasound or the echo and they're looking and you see the four chamber view and go oh my look at that right ventricle it's not very full what volume would you like yeah you're going to look really good you look really good so you can look at that not on the exam but something to remember and then the electrolytes are our physical assessment of the patient includes your physical examination laboratory findings and medications they all go together in your vital signs and in your assessment so you have to put all the pieces together the questions are not simple questions they're complicated questions really carefully the way I take the exam is I read the answers first then I read the question then I pick it almost every question on the exam has two correct answers so if you just go with the first one you read and you don't read all the rest of them you might be making a really sad mistake and you won't do well read all the answers read the question and pick your question all right this is it for assessment and extra stuff now next time remember the next module is going to start with pathophysiology thank you and see you in the next module

Channel: MED-ED

Views: 12,434

Rating: 4.9160838 out of 5

Keywords: CMC/CSC, CMC, CSC, Nursing, Continuing Education, Google, Search Engine Optimization, Video, Presentation, RN, Certification, ANCC, CE Credits, Contact Hours, Exam Review, Critical Care, Registered Nurse, Test Review, Study, Practice Test, Test Prep, ICU, House-Fancher, Nursing Continuing Education, Nurse Educator, Cardiac Medicine, Cardiac Surgery, Cardiac, Study Materials, Exam Guide, Test Plan, MED-ED, MEDED, Nurse, Online, eLearning, CE Certificate, Study Guide

Id: klqx0fPWRWA

Length: 65min 40sec (3940 seconds)

Published: Wed Oct 17 2018