THE
HEART
IN DETAIL
HEAR T STRUC TURE
PERICARDIUM
Outer layer, holds
heart in position, fluid
in pericardial space
lubricates heart
MYOCARDIUM
Middle layer, thickest,
muscle, sensitive to
changes in oxygenation
ENDOCARDIUM
Inside layer, smooth,
covers valves
DEFINITIONS
HEART VALVES
ACTION POTENTIAL
Pulmonary
Veins
Change in electrical voltage in cardiac cells
Venae
Cavae
AFTERLOAD
Right
Atrium
Resistance that the heart pumps
against - arterial vasculature.
Left
Atrium
AUTOMATICITY
Mitral
Valve
Tricuspid
Valve
Pulmonary
Artery
CARDIAC INDEX
Left
Ventricle
Right
Ventricle
Spontaneous excitation and
firing of cardiac cells
Cardiac output standardized for body mass
Aorta
CARDIAC OUTPUT
Volume of blood pumped per minute: HR x SV
DIASTOLE
Relaxation of the heart
INOTROPE
Increases force of contraction
HEART SOUNDS
CHRONOTROPE
Increases rate of contraction
PRELOAD
Volume of fluid entering the heart
SYSTOLE
Contraction of the heart measured by systolic blood pressure
S4
S1
S2
S3
BLOOD CIRCULATION
SEQUENCE OF EVENTS
SEQUENCE OF EVENTS
RIGHT SIDE
LEFT SIDE
RV contracts and
forces additional
blood into RV
Blood returns
to heart from
pulmonic veins
S2
S2
Pilmonic closes
Venous return:
Low pressure valves
maintain flow
Aortic valve closes
S1
S1
Tricuspid closes
Mitral closes
When atrial pressure
builds, mitral valve
opens and blood
flows to LV
RV contracts,
pushing blood
into pulm system
Ventricular
contraction
- Systolic wave
- PMI
Atrial contract,
forcing additional
blood into LV
1 Venous return from periphery
2 Passive filling of right atria
3 When pressure builds, tricuspid opens and right ventricle fills
4 SA node generates impulse (P-wave)
5 RA contracts filling RV with 20-30% more blood
6 Tricuspid closes (S1)
7 Impulse conducted to ventricles (QRS Complex)
8 RV contracts pushing blood into pulmonary system
9 Pulmonic valve opens
10 After RV contradiction and ejection, pulmonic valve closes (S2)
11 Heart repolarizes (T-wave)
1 Blood returns from the pulmonary system
2 Passive filling of left atria
3 When pressure in LA rises, mitral valve opens and LV fills
4 SA node generates impulse (P-wave)
5 LA contracts filling LV with 20-30% more blood
6 Mitral valve closes (S1)
7 Impulse conducted to ventricles (QRS complex)
8 LV contracts pushing blood into systemic circulation
9 Aortic valve opens
10 After LV contraction and ejection, aortic valve closes (S2)
11 Heart repolarizes (T-wave)
N O R M A L T R AC I N G S
NORMAL EKG
for a 12-Lead
Lead I
Lead II
Lead III
AVR
AVL
AVF
V1
V2
V3
SA Node
AV Node
P-wave
Purkinje
Fibers
QRS Complex
V4
V5
T
P
PR-Interval
V6
If your EKG doesn’t look like this, have
a physician look at it STAT!
QRS
HEMODYNAMICS
FLUID VOLUME: (PRELOAD)
CALCULATION OF INFUSION RATE
• CVP (0-8 mmHg)
• PAOP (5-12 mmHg)
• JVD
• Dependent edema
•I&O
• Daily weights
dose x 60
concentration
mcg/min =
dose x wt x 60
concentration
mcg/kg/min =
HEMODYNAMIC MEDICATIONS
RESISTANCE: (AFTERLOAD)
• SVR (800-1400 dynes)
• Diastolic blood pressure
• Skin color and temp
• Capillary refill
• Organ dysfunction
PUMP PERFORMANCE
(CARDIAC OUTPUT)
• CO (4-8 L/min)
• Systolic blood pressure
• Skin color and temp
• Organ function
Med
HR
B/P
CO
Dose
Dopamine
á
á
á
2-20 ug/kg/min
Dobutamine
á
á
á
5-15 ug/kg/min
Levophed
á
á
á
2-12 ug/min
Epinephrine
á
á
á
1-10 ug/min
Digoxin
â
á
á
0.125-0.5 mg
Nitroglycerine
—
â
á or â
5-20 ug/min
Nitroprusside
á
â
â
0.1 - 10 ug/kg/min
Amiodarone
â
â
á
300 mg IVP
PACEMAKERS
Chamber
paced
Chamber
sensed
Response
to sensing
Programmability
Antitachycardia
functions
O = None
O = None
O = None
O = None
O = None
A = Atrium
A = Atrium
T = Triggered
S = Simple
P = Pacing
V = Ventricle
V = Ventricle
I = Inhibited
M = Multiple
S = Shock
D = Dual
D = Dual
D = Dual
C = Communicating
D = Dual
CARDIAC
DIAGNOSTIC
TESTS
MYOGLOBIN
rises early, not specific to heart
TROPONIN
released during injury (unstable
angina)
CPK-MB
released during infarction
(myocardial infarction)
FAILURE TO DISCHARGE:
• Pacemaker doesn’t fire when heart rate is below set rate
• Watch for bradycardia, hypotension, or cardiac arrest
FAILURE TO CAPTURE:
B-TYPE NATURETIC PEPTIDE
elevates during heart failure
12-LEAD EKG
• Pacemaker doesn’t make the heart beat.
• Watch for bradycardia, hypotension, or cardiac arrest
diagnostic
TELEMETRY MONITOR
monitoring
FAILURE TO SENSE:
ECHOCARDIOGRAM
• Pacemaker fires when it shouldn’t
• Pacemaker fires close to the QRS
• Can stimulate lethal arrhythamia
shows structure and function of heart
STRESS TEST
demonstrates ischemic response to
exertion
OTHERS TO CHECK
AUTOMATIC IMPLANTABLE CARDIAC
DEFIBRILLATORS
• Serum electrolytes
• Complete blood count
• Coagulation tests
• Lipid profiles
AICDS:
A device similar to a pacemaker, that can pace,
cardiovert, or defibrillate.
CARDIAC
MEDICATIONS
PACING:
Provides electrical impulses to stimulate the
heart to contract.
ACE-Inhibitors: (end in pril):
vasodilation, reduces afterload
Captopril (Capoten)
Enalapril (Vasotec)
Lisinopril (Zestril)
Enalaprilat (Vasotec IV)
CARDIOVERSION:
Low-energy electrical shock to fully depolarize the
heart and allow normal impulse conduction.
DEFIBRILLATION:
High-energy electrical shock to fully depolarize the heart and allow normal
electrical conduction.
Complications
Possible causes
Treatment
Inappropriate shock
Atrial fibrillation
Inappropriate sensing
Magnet inhibition
Failure to deliver shock
Failure to sense, lead
fracture, inactivation
Activate device
ACLS
Ineffective cardioversion
Lead problems
Inadequate voltage
ACLS
Angiotensin-receptor Blockers:
(end in sartan) same as ACE-i
Losartan (Cozaar)
Valsartan (Diovan)
Irbesartan (Avapro)
Candesartan (Atacand)
Beta-blockers (end in olol):
blocks SNS, slows heart,
vasodilation, decreases workload
on heart, reduces afterload
Atenolol (Tenormin)
Labetolol (Normodyne)
Metoprolol (Lopressor)
Propanolol (Inderal)
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