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ObjectivesObjectives
Left Ventricular FailureRight Ventricular FailurePulmonary EdemaCor PulmonaleAcute Pulmonary EmbolismEKG’s
Left Ventricular FailureLeft 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 men5 times for women
Left Ventricular FailureLeft Ventricular Failure
The failure of the LV to effectively pump forward
Synonymous with CHF Acute CHF
Rapid Chronic CHF
SlowMidnight Shoppers
LVFLVF
Common CausesSystemic HTN– Afterload
Coronary Artery Disease– Arteriosclerosis/Atherosclerosis
Ischemia– Local/temporary occlusion
LVFLVF
Common CausesInfarction– Permanent, necrosis
Cardiomyopathy– Diseased heart muscle
tissueETOHEnlargement
LVF LVF
Fluid will collect in LASmall & Relatively incapable
Pulmonary Vasculature FillsPulmonary Congestion Occurs
Pulmonary Edema 2nd to LVF
LVF S/SLVF S/S Generalized
Weakness Fatigue Chest Pain
May be masked by respiratory complaint
Anxiety Dyspnea
LVF S/SLVF S/S
TachypneaOrthopneaParoxysmal Nocturnal Dyspnea
Elevation of pulmonary venous & cap pressuresWakening from sleep
Decrease in exercise tolerance
LVF S/SLVF S/S
Rales Wheezes
Reflex Airway SpasmCardiac Asthma
Rhonchi (Larger airway) Dull percussion at lung bases
Right Ventricular FailureRight Ventricular Failure
Causes#1 Cause of RVF is LVFStenosis:– Pulmonary valve– Mitral Valve
Pulmonary Vascular HTNRV AMI
RVF – Who CaresRVF – Who Cares
Inability of RV to pump forward
Overwhelmed by venous return
Backflow in systemic circulation
RVF – S/SRVF – S/S Tachycardia Venous Congestion Engorged Liver, spleen JVD Peripheral Edema
Dependent EdemaPitting EdemaSacral (Bedridden)
RVF-S/SRVF-S/S Ascites
Accumulation of serous fluid in peritoneal cavity – Taber’s 19th
Pleural Effusion Peripheral Cyanosis Tachy if isolated RVF Right sided hypertrophy
X-ray
RVF – S/SRVF – S/S
Clubbing of fingersDx: Chronic Hypoxia with RHF
Most of the other LVF S/S also CP SOB Tachypnea Anxiety Etc…
Cor PulmonaleCor Pulmonale
Cause of RVF
Pulmonary Parenchymal or vascular disease
CP is a disease process
Case Scenario Explanation
Cor Pulmonale – CaseCor Pulmonale – Case
58 yo maleHx of Chronic bronchitis or emphysema
Typical S/S of bronchitisProgression
Deterioration of Pulmonary capillariesAlveolar FibrosisChronic Hypoxemia
Cor Pulmonale – Case 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
Cor Pulmonale – Case Cor Pulmonale – Case
Patient displays all signs of:RVF
Initial causative pulmonary conditionVoila’
Treatment of RVF & LVFTreatment of RVF & LVF
CHF a circumstance not a DxTreatment objectives
Decrease myocardial:– Workload– Oxygen demand
Increase force & efficiency of contractionReduce fluid retention
TxTx
Vasodilatory Therapy (Nitrates)– AMI reperfusion– Container expansion reduces preload
Increase ContractilityShock algorithm directs– Dopamine– Dobutamine– Norepinephrine
DefinedDefined
Blood clot lodged in pulmonary artery
Blocks pulmonary artery flow
Supplied area ceases to function
Decreased gas exchange
V/Q mismatch
HistoryHistory
Anticoagulation therapyHeparin – 1930s
Streptokinase – 1930
Urokinase – 1951
1960s – Large study of clot resolution
Recently TPA
IncidenceIncidence
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
Risk FactorsRisk Factors
Deep vein thrombosis
Prolonged immobilization
Surgery
Trauma
Pelvic or femur fractures
Late pregnancy
Risk FactorsRisk Factors
Thrombophlebitis
Certain meds
Oral contraceptives
Atrial fibrillation
Smoking
Unknown
Increasing FrequencyIncreasing Frequency
Older population
Malignancies
More sedentary
Heart failure
COPD
Surgical procedures
PresentationPresentationVariable and Non-specific
DyspneaPleuritic chest painSyncopeHemoptysisRHFTachycardia
PresentationPresentation
No physical findings significantly accurateDeep venous thrombosis in proximal lower
ext. helpful for DxOnly about ½ source known
Why doesn’t lung tissue die from emboli like heart muscle?
Why doesn’t lung tissue die from emboli like heart muscle?
Lung has two blood supplies
Pulmonary and Bronchial
Share capillary beds
Pre-hospital TreatmentPre-hospital Treatment
Good Physical Exam and History
Index of suspicion
Airway
High flow O2
IV
Rapid Transport
Treatment ???Treatment ???
Heparin Thrombolytic agents
StreptokinaseTPA
Catheter fragmentation Catheter embolectomy Open-chest embolectomy
Definitive DiagnosisDefinitive Diagnosis
????AngiographicV/Q scan (venous/perfusion mismatch)
OperativeMultiple sources of evidence
Differential DiagnosisDifferential 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
List As Many Drugs As You Can That Will Dilate Blood Vessels.
List As Many Drugs As You Can That Will Dilate Blood Vessels.
Name the source
Describe why they
work
List Drugs That Cause Tachycardias.List Drugs That Cause Tachycardias.Describe why they cause increase rate change