Cardiovascular
Disorders
Immediate
management
Patient assessment
Specific problems
Risks of surgery
Pulmonary embolism
Hypertension
Pacemakers
Immediate
Management
Assess ABCs
- remember hypovolaemia due to haemorrhage or unreplaced fluid loss
is
common.
- thereafter come sepsis, cardiac dysfunction and PE.
Dyspnoea: makes
cardiac
and resp more likely; the systems are intertwined
Confusion: remember all
systems depend on the CVS, especially neural and renal.
Observe:
- pallor, poor perfusion, venous filling
- obvious blood loss from wounds / stomas / drains
- swelling / haemorrhage into chest, abdo, pelvis & oedema
Palpate:
- carotid, femoral pulses
- rate, rhythm, regularity, equality.
- swelling, distension, cap refill etc.
Auscultate:
- faintness, confusion, thirst are clues
- breathlessness; CVS and Resp symptoms intertwined and compromise
in one can affect the other
- listen to chest.
Patient
Assessment
Chart
review
As for basic assessment
Respiratory rate
- the most
sensitive
marker of the ill patient
- the first feature to change as a patient deteriorates
- accurate observation / recording is essential
- if <11 consider CNS depression, drugs, low CO
- if high, consider early shock, resp disease or cardiac failure.
Heart rate and rhythm
- enormous variation with age, disease, fitness
- consider medical conditions and drugs, esp B-blockers
- tachycardia is an early sign of shock
- acute dysrhythmia may suggest MI
Blood Pressure
- changes are late and flag a severe problem
- think perfusion, not pressure
- remember "normal" BP may be very low for an elderly hypertensive
patient.
JVP & CVP
- collapsed
neck veins at 45o suggests low CVP
- if not visible with pt flat, it is always abnormal
- trends in CVP, esp response to fluids is much more useful than
absolutes
- consider formal CVP monitoring when fluid management is becoming
problematic
--> if low: consider inadequate
replacement, bleeding, vasodilation (sepsis, epidurals), low CO.
--> if low: must be
corrected in the face of hypotension
--> if high:
consider temporary elevation post fluids, fluid overload, RVF, CHF,
pulmonary hypertension, pericardial effusion.
Temperature
- may be high or low in sepsis or SIRS
- may be normal in the immunocompromised or elderly on steroids
despite
sepsis
- core/peripheral difference of >2oC suggests poor peripheral
perfusion
- low-grade pyrexia occurs post-MI, in endocarditis and diurnally in
a
warm environment (especially in the evening).
Urine Output
- the best surrogate
marker
for perfusion and CO on the ward
- excellent marker of early cardiovascular problems
- look for steady decline rather than anuria (?blocked catheter)
IV Lines
- emergency lines are more likely infected
- even peripheral ones may cause sepsis
- placement of a decent line is hard in sepsis
- tissued line cause morbidity
Tubes & Drains
- may or may not be patent
- sudden occlusion of chest drains may cause tension pneumothorax
- pericardial tamponade may follow a blocked pericardial drain
- abdo bleeding may hide if abdo drains blocked
- drainage volumes are essential in fluid balance calculations.
Drug Charts
- have cardiac
drugs
been missed while pt is nil-by-mouth?
- some drugs mask effects or have adverse side effects
Fluid Balance
- look at rate
and
type and balance over preceeding days
- has the fluid been given at the correct rate?
- some pts may be overloaded, but far more frequently underloaded.
- 'fluid creep' - several
consecutive days with positive balance can overload an old person.
History
- consider speed of problem onset
- consider any pain carefully
- what is their normal function?
Case notes
Admission,
operations,
anaesthetics, past history and medications.
Examination
Think
perfusion
Observe: confusion, ABCs,
colour, peripheries, neck veins
Palpate: skin (clammy?),
liver
for hepatomegaly, ascites.
Listen: failure (may be
wheezy
in early LVF due to small airway narrowing), assess HS.
Available results
Hb: transfusion should be
used to maintain Hb to around 8 g/dL
WCC: leukocytosis may be
present post-MI.
K+: a decrease of 1mmol/l
represents a body deficit of 200-300mmol/L.
- do not give KCl faster than 20mmol/hr.
- levels >7mmol/L will cause T-wave changes
Reassess
Remember to take action early
And Reassess
Specific
Management Problems
Hypotension / Shock
See notes
Tachyarrhythmias
Be systematic
- start with ABCs, correcting hypoxia, hypovolaemia, electrolyte
imbalance
- manoeuvres for SVT
- be careful with all drugs, if in doubt, don't give it.
- AF is a long term risk of thromboembolus
- DC cardiovert if very rapid or compromised, must anaesthetise.
- pacing and ablation may occur to a cardiologist.
Get a 12-lead ECG
Causes of tachycardia
Inflammatory: pyrexia, pericarditis
Metabolic: acidosis, thyrotoxicosis
Circulatory: anaemia, shock
Trauma: hypovolaemia
Drugs
Anxiety and pain
Causes of arrhythmia
IHD
O2 / fluid / electrolyte disturbance
Drugs
Rheumatic heart disease
Cardiomyopathy
Thyrotoxicosis
Ventricular tachycardia
protocol if collapsed
Amiodarone 5mg/kg over 20mins may be useful
Ventricular ectopics
May be unifocal (each the same) or multifocal.
Pulse irregular, seen on ECG
- danger in that an ectopic
arising
on the apex of a T will produce VF.
- consider treatment if ratio VE:QRS is >1:6 or
multifocal.
--> CCrISP book says lignocaine
Can occur in the healthy, more in elderly
- associated with electrolyte disturbance eg hypokalaemia /
hypomagesaemia, valvular disease, cardiomyopathy, hypoxia and
digitalis
toxicity.
Sinus tachycardia
Eg in hypovolaemia, anaemia, pulmonary embolism, sepsis.
Paroxysmal SVT
Regular, 150-250
At the AV node, SA node or atria.
p-waves are abnormal and may not be seen
QRS normal width unless also BBB
May be associated ST depression
CSM and adenosine are treatments
AF
see card
LVH
Anything increasing LV work causes this.
Causes LAD
- tall R's in I, aVL
- s-waves in III, aVF.
- tall R's in V4-V6
- deep S's in V1-V3
RVH
Conditions causing high RV afterload
- eg pulmonary hypertension
- cor pulmonale, pulmonary stenosis
Causes RAD, tall R in V1, deep S in V6.
- tall pulmonary p suggests right atrial hypertrophy.
LBBB & RBBB
MorroW --> Left
WilliaM --> Right
- RBBB with LAD suggests bifascicular block - seek help as may need
pacing.
- associated with IHD, VHD, hypertrophy, fibrosis, cardiomyopathy.
Bradyarrhythmia
Problematic if causing hypoperfusion / hypotension
- pts with heart block, eg bifascicular block need screening pre-op
and
likely pacing.
Atropine 0.6-1 mg may help
- pacing may be needed
- discuss early.
Acute coronary syndrome & MI
seek physician help early.
Congestive heart failure
Risks
of surgery
See cardiac preassessment notes
Pulmonary
Embolism
See notes
Hypertension
Avoid stopping long-term meds suddenly
- unless the pt is hypotensive
- be aware for side-effects in post-op pts.
Get pain under control post-op.
Consider GTN patch or amlodipine
Pacemakers
See cardiac preassessment notes