Cardiovascular Emergencies

CHAPTER 11 Cardiovascular Emergencies



Laura M. Criddle, PhD(c), RN, CEN, CCNS, CFRN, FAEN



MAJOR TOPICS



General Strategy


Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Medical Cardiovascular Emergencies


Acute Coronary Syndromes

Right Ventricular Infarction

Chronic Stable Angina Pectoris

Heart Failure and Cardiogenic Pulmonary Edema

Myocarditis

Cardiomyopathy

Pericarditis

Infective Endocarditis

Cardiac Dysrhythmias

Sinus Dysrhythmias

Atrial Dysrhythmias

Junctional Dysrhythmias

Atrioventricular Node Conduction Disturbances/Heart Block

Ventricular Dysrhythmias

Hypertensive Emergencies

Acute Aortic Dissection

Peripheral Venous Thrombosis

Peripheral Vascular Disease

Acute Arterial Occlusion


I. GENERAL STRATEGY



A. Assessment




1. Primary and secondary assessment/resuscitation (see Chapter 1)


2. Focused assessment


a. Subjective data collection

1) History of present illness/chief complaint
a) Pain: PQRST (see Chapter 9)
(1) Provocation

(2) Quality

(3) Region/radiation

(4) Severity of symptoms

(5) Temporal factors
(a) Onset: when symptoms started

(b) Duration: length of time symptoms lasted; constant versus intermittent

(c) Changes over time (e.g., from dull to sharp)

(d) Temporality: symptoms associated with a particular time of day, time of year

(e) Frequency: first episode or frequent or chronic problem

b) Dyspnea
(1) Dyspnea on exertion (DOE)

(2) Dyspnea when lying down (orthopnea)

(3) Paroxysmal nocturnal dyspnea (PND)

c) Cough
(1) Dry, “cardiac” cough

(2) Hemoptysis, or copious, pink, frothy sputum (pulmonary edema)

d) Syncope, fatigue, weakness, lightheadedness

e) Palpitations

f) Nausea, vomiting

g) Headache

h) Altered mental status, behavioral changes

i) Activity limitations, sleep disturbances

j) Efforts to relieve symptoms
(1) Home remedies

(2) Alternative therapies

(3) Medications
(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history
a) Current or preexisting diseases/illness
(1) Acute coronary syndromes (ACSs)
(a) Angina: stable, unstable

(b) Previous myocardial infarction (MI)

(2) Hypertension (HTN)

(3) Heart failure

(4) Pulmonary disease

(5) Diabetes mellitus

(6) Renal disease

(7) Vascular disease: arterial or venous
(a) Peripheral

(b) Cerebral

b) Cardiac surgery or other cardiac interventions

c) Congenital anomalies

d) Substance and/or alcohol use/abuse

e) Smoking

f) Last normal menstrual period: female patients of childbearing age

g) Current medications
(1) Prescription
(a) Nitrates

(b) Beta-blockers

(c) Calcium channel blockers

(d) Antihypertensives

(e) Digitalis glycosides

(f) Diuretics

(g) Angiotensin-converting enzyme (ACE) inhibitors

(h) Antidysrhythmics

(i) Anticoagulants
(i) Antiplatelet agents (aspirin, clopidogrel [Plavix])

(ii) Warfarin (Coumadin), heparin

(j) Steroids

(k) Pulmonary-specific drugs

(l) Erectile dysfunction medications

(2) Over-the-counter/herbal

h) Allergies

3) Psychological/social/environmental factors
a) Unmodifiable
(1) Age: the incidence of cardiac disease increases with age

(2) Gender: male sex predominates, particularly among younger patients

(3) Genetics: family history is a strong predictor of cardiac disease

(4) Race/ethnicity: blacks/African Americans have a higher incidence than whites, American Indians, or Asians

b) Modifiable
(1) Blood pressure (BP)

(2) Obesity, diet

(3) Dyslipidemia

(4) Smoking

(5) Sedentary lifestyle

(6) Stress

(7) Possible/actual assault, abuse, or intimate partner violence situations (see Chapter 3)

b. Objective data collection

1) General appearance
a) Level of consciousness, behavior, affect

b) Vital signs
(1) Respiratory rate, effort, pattern

(2) BP
(a) Both arms: significant differences greater than 10 mm Hg

(b) Orthostasis: supine, sitting, standing

(3) Peripheral pulses: bounding, normal, diminished, absent

c) Odors

d) Gait

e) Hygiene

f) Level of distress/discomfort

2) Inspection
a) Skin color: cyanosis
(1) Central: present when cardiac output is severely decreased

(2) Peripheral: indicates decreased blood flow to the periphery

b) Edema
(1) Dependent: extremities, sacrum

(2) Pitting: cardiac

c) Clubbing of the fingers: associated with congenital heart disease

d) Pupils
(1) Size

(2) Equality

(3) Reaction to light

e) Neck veins: flat, normal, distended

f) Thorax
(1) Configuration: symmetry, deformities, anteroposterior diameter, kyphosis, chest wall movement with respiration

(2) Scars or objects: surgical incision, pacemaker, automatic implanted cardioverter-defibrillator (AICD), implanted venous catheter, medication patch

g) Precordium: abnormal precordial movements (e.g., heaves, lifts)

h) Epigastric and abdominal pulsations, ascites, venous distention

i) Cardiac dysrhythmias on monitor

3) Auscultation
a) Breath sounds
(1) Depth

(2) Equality

(3) Location of bronchial, vesicular, and bronchovesicular sounds

(4) Adventitious sounds: crackles (fine or coarse), wheezes, friction rub (harsh, grating sound that is often positional)

b) Heart sounds
(1) Apical heart rate
(a) Rate: regular, tachycardia, or bradycardia

(b) Rhythm: regular, regularly irregular, or irregularly irregular

(2) Auscultatory sites: aortic valve (second right intercostal space [ICS]), pulmonic valve (second left ICS), tricuspid valve (lower left sternal border), mitral valve (apex), Erb’s point (third left ICS), epigastric area (below the xiphoid)

(3) S1 and S2: S1, mitral and tricuspid valves close; S2, aortic and pulmonic valves close

(4) S3 and S4: S3, can be normal in children, young adults, pregnant women, and some elderly patients; the presence of S4 is always abnormal

(5) Murmurs: systolic or diastolic, location, grade (I to VI)

(6) Variations related to dysrhythmias: premature extra systoles, atrial fibrillation, complete heart block

(7) Extra cardiac sounds: pericardial friction rub, venous hum, click, carotid bruits

4) Palpation
a) Skin temperature, moisture

b) Capillary refill time

c) Areas of tenderness

d) Precordial area
(1) Point of maximal impulse (PMI); usually located in the fifth left ICS at the midclavicular line (MCL); size is normally 2 cm

(2) Thrills: feels like a purring cat

e) Epigastrium
(1) Differentiate between abdominal aorta and right ventricular (RV) pulsations

3. Diagnostic procedures


a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serum chemistries including magnesium, glucose, blood urea nitrogen (BUN), and creatinine

3) Cardiac biomarkers (troponin I, troponin T, myoglobin)

4) B-type (or brain) natriuretic peptide (BNP)

5) Lipid panel

6) Coagulation profile: prothrombin time, international normalized ratio (PT-INR); activated partial thromboplastin time (aPTT)

7) D-dimer

8) Erythrocyte sedimentation rate (ESR)

9) Digoxin level

10) Arterial blood gas (ABG)

11) Urinalysis; pregnancy test in female patients of childbearing age

12) Serum and urine toxicology screen

13) Type and crossmatch

b. Imaging studies

1) Chest radiograph
a) Heart size and location

b) Presence of interstitial edema, pulmonary infiltrates, or pleural effusion

c) Mediastinal width

d) Aortic calcifications

2) Echocardiography
a) Transthoracic (TTE)

b) Transesophageal (TEE)

3) Cardiac computed tomography (CT) scan: with or without contrast

4) Cardiac magnetic resonance imaging (MRI)
a) Use a non–iodine-based enhancing agent (e.g., gadolinium–diethylenetriamine penta-acetic acid [DTPA])

b) Identifies and evaluates hypertrophy, areas of cardiac infarction or ischemia, pulmonary artery disease, RV abnormalities, pericardial disease, cardiac tumors, valvular disorders, thoracic aortic disease, and congenital heart disease

5) Aortography

6) Nuclear scintigraphy

7) Venography

8) Abdominal sonography

9) Doppler sonography (extremities)

10) Bubble echocardiography

c. Other

1) 12-lead, 15-lead, 18-lead, or right-side electrocardiogram (ECG)

2) Cardiac catheterization
a) Diagnosis: angiography identifies areas of obstruction

b) Treatment: angioplasty, stent placement

3) Exercise stress testing

4) Electrophysiologic mapping


B. Analysis: Differential Nursing Diagnoses/Collaborative Problems




1. Decreased cardiac output


2. Ineffective tissue perfusion: cardiac, cerebral, renal, or peripheral


3. Acute pain


4. Excess fluid volume


5. Impaired gas exchange


6. Deficient knowledge


7. Anxiety



C. Planning and Implementation/Interventions




1. Determine priorities of care


a. Maintain airway, breathing, and circulation (see Chapter 1)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluid/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension


3. Allow significant others to remain with patient if supportive


4. Educate patient and significant others



D. Evaluation and Ongoing Monitoring (see Appendix B)




1. Continuously monitor and treat as indicated


2. Monitor patient response/outcomes, and modify nursing care plan as appropriate


3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care



E. Documentation of Interventions and Patient Response




F. Age-Related Considerations




1. Pediatric


a. Growth or development related

1) Congenital heart disease

2) Acquired heart disease (e.g., rheumatic fever)

3) Endocrine or metabolic disorders (e.g., diabetes, pheochromocytoma)

4) Drug ingestion (e.g., tricyclic antidepressants, beta-blockers, calcium channel blockers, digoxin, stimulants)

b. “Pearls”

1) Cardiac arrest in the pediatric population is usually the result of progressive deterioration in respiratory and circulatory function, rather than the result of a sudden cardiac event

2) The presence of heart failure, cardiogenic shock, or multiple dysrhythmias in the pediatric patient is usually related to congenital cardiac anomalies

3) Autonomic immaturity contributes to bradydysrhythmias in infants

4) Tachydysrhythmias may be the result of congenital conduction system anomalies such as Wolff-Parkinson-White (WPW) or Long-Ganong-Levine (LGL) syndromes

2. Geriatric


a. Aging related

1) The presence of chronic diseases may obscure or confound the cardiac picture

2) Drug metabolism is altered (generally slowed) in the elderly; drug interactions may further decrease drug metabolism

3) Older individuals have multiple physiologic differences (e.g., diminished responses to stress, decreased hepatic and renal function, changes in laboratory values) that must be taken into account during assessment

4) Psychological and social differences: older adults may have different goals for their treatment plan regarding prolonging life and the use of life support

5) Some older adults adapt so well to cardiac disease that signs that would otherwise be remarkable go undetected

6) Arteriosclerotic changes in the aorta and peripheral circulation may make it difficult to palpate pulses

7) Rhythm abnormalities are so common among elderly patients that they are often the patient’s norm

8) In older adults, the venodilatory effect of nitroglycerin is greater; because of normal mouth dryness, the onset of action for sublingual nitroglycerin can be prolonged, and nitroglycerin spray may be a better choice

9) Adverse beta-blocker effects are more common and more severe in the elderly

b. “Pearls”

1) “Start low, go slow” when treating the elderly with pharmacologic agents

2) Concurrent use of multiple medications (polypharmacy) poses a variety of problems for the older patient; frequent reevaluation of all medications (medication reconciliation) is essential for preventing complications

3) In older patients, typical angina-equivalent symptoms include weakness, dyspnea, syncope, acute confusion, and stroke

4) Unexplained sinus tachycardia, cardiac asthma, and new-onset lower extremity edema have also been reported as angina equivalents in the elderly

5) Among the very elderly, assess for neurologic presentations of cardiovascular problems (e.g., acute mental status changes, new-onset weakness, stroke)

6) The incidence of asymptomatic MI in persons aged 75 to 84 years is more than 40%


II. SPECIFIC MEDICAL CARDIOVASCULAR EMERGENCIES



A. Acute Coronary Syndromes


The term acute coronary syndromes is used to refer to patients presenting with chest pain or other discomfort resulting from a continuum of cardiac ischemic processes: (1) unstable angina (UA), (2) non–ST-segment elevation MI (NSTEMI), and (3) ST-segment elevation MI (STEMI). Prolonged myocardial ischemia produces necrosis, referred to as myocardial infarction. Most MIs occur as a result of coronary artery atherosclerosis, followed by rupture of an unstable atheromatous plaque, platelet activation, and fibrin clot formation. The resultant thrombosis interrupts blood flow and leads to an imbalance between myocardial oxygen supply and demand. Nonatherosclerotic causes of MI include coronary artery spasm, congenital abnormalities, coronary artery embolus, and connective tissue disorders.


Regardless of the initial cause, if the myocardial oxygen supply-demand imbalance is severe or persistent, ischemia will produce irreversible cellular damage. The subsequent impact on myocardial contractility, stroke volume, and ventricular function will depend on the duration of ischemia, the extent of myocardial tissue involvement, and the patient’s preexisting cardiac status. Myocardial ischemia also stimulates catecholamine release, which increases peripheral vascular resistance, promotes tachycardia, and raises both preload and afterload. This increased demand on an infarcting myocardium can be overwhelming. Because many other conditions produce symptoms similar to those of ACS, careful examination and history taking are essential. Differential diagnoses include esophageal spasm, gastroesophageal reflux disease, biliary colic, chest wall pain, pericarditis, pulmonary embolism, aortic dissection, and cardiac dysrhythmias. Because each of the three ACSs is produced by the same underlying disease process, these syndromes are distinguished physiologically only by the extent of myocardial injury. Risk factors, assessment parameters, and many interventions are identical for all patients with ACS. Additionally, ACSs are currently an area of intense research; assessment and treatment recommendations change frequently. The development and implementation of a protocol or algorithm for care of the patient with ACS can help streamline the approach to this population (Fig. 11-1).


image

FIGURE 11-1 Acute coronary syndrome clinical guidelines.


(Modified from Cigarroa, J., MD, Davies, C., MD, & Johnson, K., RN MS CNS CCRN, Oregon Health & Science University, Portland, Oregon.)




1. Assessment(Table 11-1)


a. Subjective data collection

1) History of present illness/chief complaint
a) Pain or “discomfort” (see Chapter 9)
(1) Provocative factors: activity that increases myocardial oxygen requirements
(a) Physical activity/exercise

(b) Emotional stress

(c) Cold weather

(d) After meals

(e) Sexual activity

(f) May occur at rest

(2) Palliative factors: unrelieved by change in position or nitrate use

(3) Quality: pain may be “different” from the patient’s usual angina; quality may be described as squeezing, crushing, stabbing, knifelike, heaviness, pressure, or “something sitting on my chest”; may also be described as tightness, burning or indigestion, especially by women or older adults

(4) Region/radiation: chest, substernal area, epigastrium, neck, infrascapular region, jaw, or ulnar aspect of the left arm or elbow producing tingling in the wrist, hand, and fingers

(5) Severity of symptoms: can range from vague to severe; generally more intense than the patient’s usual angina

(6) Temporal factors: time of onset; continuous or lasting more than 30 minutes; circadian variability (peaks from 6 AM to noon, usually in the first 2 to 3 hours after arising)

b) Nausea or vomiting

c) Dyspnea or orthopnea

d) Diaphoresis

e) Fatigue, sleep disturbances, and dyspnea, especially in women

f) Weakness or dizziness, especially in older adults

g) Palpitations

h) Syncope

i) Feeling of impending doom

2) Past medical history
a) Current or preexisting diseases/illness
(1) Angina

(2) Previous MI

(3) HTN (increases cardiac workload)

(4) Cerebral vascular disease/stroke

(5) Diabetes mellitus: increases the incidence of MI; patients are more likely to experience vague symptoms or “silent” MI

(6) Dyslipidemia

b) Previous cardiac interventions (e.g., angioplasty, valve replacement, coronary artery bypass grafting, stent insertion, pacemaker, or AICD placement)

c) Thromboembolic event

d) Other cardiac risk factors
(1) Age: greater than 65 years of age

(2) Smoking

(3) Obesity

(4) Sedentary lifestyle

(5) Recreational drug or alcohol use

e) Medications
(1) Recent use of erectile dysfunction medications

f) Allergies

b. Objective data collection

1) Physical examination
a) General appearance
(1) Level of consciousness, behavior, affect: anxious, restless

(2) Clenched fist against the sternum (Levine’s sign)

(3) Tachycardia, bradycardia

(4) Possible hypotension/hypertension

(5) Tachypnea

(6) Possible elevated temperature: initially normal, then begins to rise 4 to 8 hours after MI onset as a nonspecific response to tissue necrosis

(7) Moderate to severe distress/discomfort, critically ill

b) Inspection
(1) Pale, diaphoretic, possible cyanosis or mottled coloring

(2) Cardiac dysrhythmias on monitor

c) Auscultation
(1) Heart sounds
(a) S4 is almost universally present

(b) S3 indicates left ventricular (LV) dysfunction

(c) Murmurs: may be transient or permanent; indicate valve dysfunction

(d) Muffled sounds indicate effusion

(2) Breath sounds: possible crackles, wheezes

d) Palpation
(1) Cool skin

(2) Peripheral pulses: variable

2) Diagnostic procedures
a) Cardiac biomarkers: elevated
(1) Troponin proteins (cTnI and cTnT) most sensitive and specific for myocardial damage; they have replaced enzyme studies for the diagnosis of MI1,2
(a) Troponin levels elevate 3 to 12 hours after MI onset, peak in 24 hours (cTnI) or 12 to 48 hours (cTnT), and return to normal in 5 to 12 days

(b) Troponin elevation is not specific to MI; elevated levels are associated with several other disease states3

(c) cTnT may be elevated in patients with renal failure; cTnI is more cardiospecific

(d) Absence of troponin level elevation distinguishes UA from MI

b) CBC with differential

c) Serum chemistries including magnesium, BUN, and creatinine

d) Coagulation profile

e) Lipid panel

f) 12- to 18-lead ECG
(1) ECG changes may not be apparent initially; the ECG may be completely normal, which does not rule out MI, especially shortly after occlusion

(2) ECG findings reflect changes in the myocardium (Table 11-2)

(3) Infarct location is determined by the presence of ECG changes in specific leads (Table 11-3); an infarct may involve more than one area of the heart

(4) Right-sided ECG in patients with changes suggestive of inferior MI to determine presence of posterior MI

(5) Repeat ECGs are helpful for detecting ongoing changes, which may lag behind symptoms

g) Chest radiograph

h) Echocardiogram: evaluate wall motion and perfusion; particularly useful in patients with NSTEMI

2. Analysis: differential nursing diagnoses/collaborative problems


a. Acute pain

b. Ineffective tissue perfusion: cardiac, peripheral

c. Anxiety

3. Planning and implementation/interventions


a. Maintain airway, breathing, and circulation (see Chapter 1)

1) Initiate or continue Basic Life Support (BLS) and Advanced Life Support (ALS) per protocols

b. Provide supplemental oxygen

1) Rapid sequence intubation (RSI) and ventilatory support for patients in cardiogenic shock

2) High-flow oxygen

c. Establish IV access for administration of crystalloid fluid/medications

1) Insert a minimum of two IV catheters

d. Prepare for/assist with medical interventions

1) Advanced airway management
a) Nasal or oral intubation

b) Laryngeal mask airway

c) Combitube

d) Surgical airway (e.g., cricothyrotomy)

2) Institute cardiac and pulse oximetry monitoring

3) Assist patient with position of comfort

4) Catheter placement and monitoring of pulmonary wedge pressure (see Chapter 7)

5) Cardiac pacing, defibrillation, ventricular assist devices for patients in cardiogenic shock

6) Insert gastric tube and attach to suction

7) Insert indwelling urinary catheter

8) Assist with hospital admission or transfer to an institution providing a higher level of care
a) Cardiac catheterization

b) Percutaneous coronary interventions (PCIs)

e. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Aspirin unless administered prior to arrival either by self or prehospital care providers; if the patient is allergic to aspirin, administer clopidogrel (Plavix)

3) Metoprolol (Toprol, Lopressor) or sublingual nitrates: up to three doses, 5 minutes apart
a) Until symptoms are relieved, systolic BP falls below 90 mm Hg, or maximum dose has been reached

4) Narcotics
a) Morphine sulfate is used for severe angina when nitroglycerin has not been effective

b) Morphine sulfate provides both analgesia and sedation, decreases preload and afterload, and reduces apprehension

5) Glycoprotein IIb/IIIa inhibitor (e.g., eptifibatide [Integrilin], abciximab [ReoPro]) bolus and a continuous infusion in high-risk patients and patients with NSTEMI or STEMI

6) Heparin bolus and initiate a heparin infusion or administer low-molecular-weight-heparin (enoxaparin [Lovenox]) in patients with STEMI

7) If PCIs are not readily available, consider fibrinolytic therapy for patients with STEMI
a) Evaluate whether the patient meets guidelines for fibrinolytic therapy

b) Avoid arterial sampling and other invasive procedures as much as possible

8) ALS medications per protocols

9) Antidysrhythmics, vasopressors, vasodilators, and inotropic agents for patients in cardiogenic shock from MI

4. Evaluation and ongoing monitoring (see Appendix B)


a. Airway patency

b. Level of consciousness

c. Hemodynamic status

d. Breath sounds and pulse oximetry: pulmonary congestion may occur in patients with significant LV failure

e. Cardiac rate and rhythm

1) Ventricular ectopy

2) Atrioventricular (AV) blocks

3) Tachycardia or bradycardia

4) Reperfusion dysrhythmias

f. Pain relief

g. Intake and output

h. Internal/external bleeding in patients receiving fibrinolytic therapy


Table 11-1 ACUTE CORONARY SYNDROMES

image


Table 11-2 ELECTROCARDIOGRAPHIC SIGNS OF MYOCARDIAL INFARCTION

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Nov 8, 2016 | Posted by in NURSING | Comments Off on Cardiovascular Emergencies

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