Lecture 3 Cardiac Drugs

LECTURE 3 Cardiac DRUGS CALCIUM-CHANNEL BLOCKERS Calcium-Channel Blockers are like Valium for your heart • Valium -> calm’s you down; so CCB’s calm your heart down (ex. if tachycardic, give CCB’s but not in shock)! - to REST YOUR HEART! - not stimulants • calcium-channel blockers are negative inotropic, chronotropic, & dromotropic drugs! - fancy way of saying that they calm the heart down Inotropes Chronotropes Dromotopes POSITIVE NEGATIVE Cardiac Stimulants - stimulate, speed ! up the heart Cardiac Depressants! - calm the heart down, ! weaken & slow down • When do you want to “depress” the heart? What do CCB’s treat?! A: anti-hypertensives! - relax heart & blood vessels to bring down BP! AA: anti-angina’s! - relax heart to use less O2 to make angina go away! - treats angina by addressing oxygen demand! AAA: anti-atrial arrhythmia! - ex. atrial flutter, A-fib, premature atrial contractions! - never ventricular! *** what about supra-ventricular tachycardia?? ! -> because it means ‘above the ventricles’ (which ! are the atria) • Side-Effects:! H & H = headache & hypotension! -> hypoTN - from relaxed heart & vessels! -> headache - vasodilation to brain! ** Hint: headache is a good thing to select for ! ‘select all that apply’ questions (ex. low Na & high ! Na = headache, high & low glucose = headache, high & ! low BP = headache) • Names of Calcium-Channel Blockers:! - anything ending in ‘-dipine’! - ex. amlodipine, nifedipine! - NOT just ‘-pine’! - also includes: VERAPAMIL & CARDIZEM! - which can be given as continuous IV drip??! = Cardizem • What VS needs to be assessed before giving a CCB?! - BP = because of risk of hypoTN! -> parameters/guidelines - hold CCB if systolic is ! under 100 ! -> so you need to monitor BP if PT is on a Cardizem ! continuous drip (if it’s under 100 then you may ! have to stop or change the drip rate) CARDIAC-ARRYTHMIAS • Interpreting Rhythm Strips (4 that need to be known by sight):! a) Normal Sinus Rhythm! = P wave before every QRS & followed by a T ! wave for every single complex! -> all P wave peaks are equally distant from each ! other, QRS evenly spaced! b) V-Fib = chaotic squiggly line, no pattern! c) V-Tach = sharp peaks, has a pattern! d) A-Systole = flat-line! • Terminology:! - if QRS depolarization, it’s talking about ventricular ! (so rule out anything atrial)! - if it says P-wave then it’s talking about atrial! • 6 Rhythms most tested on N-CLEX:! 1. “a lack of QRS’s” = A-systole! - flat-line, no QRS! 2. “P-wave” = Atrial! - if it’s a sawtooth wave, always pick atrial flutter! 3. “chaotic” - A-fib if w/ P-wave! 4. “chaotic” - V-fib if w/ QRS ! - Hint: the word ‘chaos’ is used for fibrillation! 5. “bizarre” = atrial tachycardia if w/ P-wave! 6. “bizarre” = ventricular tachycardia if w/ QRS! - Hint: the work ‘bizarre’ is used for tachycardias • PVC’s (premature ventricular contractions)! = a.k.a. periodic wide bizarre QRS! - ventricular because QRS! - bizarre -> tachycardia! - you can call a group of PVC’s a short run of V-tach! - do Physician’s care about PT’s having PVC’s?! -> NO, not a high priority = low priority! -> 3 circumstances when you could elevate these ! PT’s to moderate priority (never reach high)! i. if there are more than 6 PVC’s in a minute! ii. if there are more than 6 PVC’s in a row! iii. if the PVC fall on the T-wave of the previous ! beat (R on T phenomenon)! -> most common order if you call the MD about a ! PT w/ PVC’s = D/C monitor (because then you ! can’t see the PVC’s and then you won’t call them) • Lethal Arrhythmia’s:! - HIGH PRIORITY, 2 main ones (will kill you in 8 mins ! or less) -> these PT’s will probably be top priorities! a) A-Systole! b) V-Fib! ** both have in common = no cardiac output! -> no brain perfusion (and you’ll be dead in 8 mins) • V-tach = potentially life-threatening (but not actually life-threatening), but still makes it a fairly high priority! - difference is that these PT’s have cardiac output • in codes, even if the rhythm changes, if there is no cardiac output it’s just as bad as the previous rhythm • Treatment (more drugs):! a) PVC’s b) V-tach! = for ventricular use LIDOCAINE/AMIODARONE! * in rural areas more Lidocaine use (cheaper & ! longer shelf-life)! c) Supra-Ventricular Arrhythmia’s! = atrial arrhythmia’s use ABCD’s! • A -> ADENOCARD (Adenosine)! - have to push in less than 8 seconds (FAST IV ! push) -> slam this drug, followed by a flush; use a ! big vein; BUT the problem w/ slamming it fast is ! the risk of PT going into A-Systole (for 30 seconds ! but they will come out of it so don’t worry [unless ! longer than 30 sec…])! ** for IV pushes: when you don’t know you go slow! • B -> BETA-BLOCKERS! - all end in ‘-lol’! - every ‘-lol’ is a BB & every BB is a ‘-lol’! - are negative inotropes, chronotropes, & ! dromotropes like calcium-channel blockers (a.k.a. ! valium for your heart so they treat A, AA, AAA & ! have same side-effects)! ** generally speaking, don’t make a big difference ! between Beta- & Calcium channel blockers; ! except that CCB are better for PT’s w/ asthma ! or COPD -> Beta-B’s bronchoconstrict ! • C -> CALCIUM-CHANNEL BLOCKERS! - see Beta-Blockers & CCB’s earlier! • D -> DIGITALIS (DIGOXIN, LANOXIN)! d) V-Fib! = for V-fib you D-fib (shock them!)! e) A-Systole! = use EPINEPHRINE & ATROPINE (in this order!)! -> if epinephrine doesn’t work then use atropine CHEST TUBES • purpose is to re-establish negative pressure in the pleural space (so that the lung expands when the chest wall moves)! - pleural space -> negative is good (negative pressure ! makes things stick together)! - ex. gun shot to the lung add positive pressure • Hint: when you get a chest tube question, look at the reason for which it was placed (will tell you what to expect & what not to expect)! - ex. pneumothorax = to remove air (because air ! created the positive pressure)! - ex. hemothorax = to remove blood! - ex. pneumohemothorax = to remove blood & air! • Hint: Also, pay attention to the location of the tubes:! a) Apical = the chest tube is way up high, thus it is ! removing air (because air rises)! - ex. it’s bad if you’re apical tube is draining 200 mL or ! it is not bubbling! b) Basilar = at the bottom of the lungs, thus it is ! removing blood/liquid (because of gravity) ! - ex. it’s bad if your basilar tube is bubbling or not ! draining any mL • ex. How many chest tubes & where would you place them for a unilateral pneumohemothorax?! - 2 chest tubes (apical for pneumo, basilar for hemo) • ex. How many chest tubes & where would you place them for a bi-lateral pneumothorax?! - 2 tubes (apical on left, apical on right) • ex. How many chest tubes & where would place them for post-op chest surgery?! - 2 tubes (apical & basilar on the side of the surgery)! ** you are to assume that chest surgery/trauma is ! unilateral unless otherwise specified (they will ! say bilateral) • Trick Question: How many chest tubes would you need and where would you place them for a post-op right pneumonectomy?! - NONE! because you are removing the lung so you ! don’t need to re-establish any pressure (there is not ! pleural space)!! Troubleshooting Chest Tubes: • What do you do if you knock over the plastic containers that certain tubes are attached to?! -> set it back up & have PT take some deep breaths! -> NOT a medical emergency! (don’t call MD) • What do you do if the water seal breaks (the actual device breaks?)! -> first = CLAMP it!!! because now positive pressure ! can get in! don’t let anything get in! -> 2nd = cut the tube away from the broken device ! -> 3rd = stick that open end into sterile water! -> then unclamp it because you’ve re-established the ! water seal (doesn’t need clamp if it’s under water! *** better for the tube to be under water than ! clamped! -> air can’t go in and stuff can still keep ! coming out (if clamped, nothing can come out ! which is what the tube is for) • Ex. If they ask what the first thing is to do if the seal breaks -> Clamp! BUT, if they ask what’s the best thing to do -> put end of tube under water! (because it actually solves the problem, clamping is a temp. fix) • Hint: ‘BEST’ vs. ‘FIRST’ questions! - first questions = are about what order! - best questions = what’s the one thing you would do if ! you could only do 1 of the options! -> ex. You notice the PT has V-fib on the monitor. You ! run to the room and they are non-responsive with ! no pulse. What is the first thing you do?! A) place a backboard?! B) begin chest compressions?! - “first” is about order so = pick A (because you ! wouldn’t start chest compressions first)! - BUT, if the question ask “What’s the best thing to ! do?” -> you only get to do 1 thing not the other so ! you would pick B • What do you do if the chest tube gets pulled out?! - first = take a gloved hand and cover the hole! - best = cover the hole with vaseline gauze • Bubbling chest tubes: (ask yourself 2 questions)! a) Where is it bubbling?! b) When is it bubbling?! = the answer will depend on these 2 questions ! (sometimes bubbling is good, sometimes bad but ! depends on where & when)! - ex. Intermittent bubbling in the water seal -> GOOD ! (document it, never bad!)! - ex. Continuous bubbling in the water seal -> BAD ! (you don’t want this, means a leak in the system that ! you need to find and tape it until it stops leaking)! ** in RPN scope! - ex. Intermittent in suction control chamber -> BAD ! (means suction is not high enough, turn it up on the ! wall until bubbling is continuous)! - ex. Continuous in suction control chamber -> GOOD ! (document it)! - Hint: both locations are opposites of each other ! (memorize one & deduce the others)! —> if there is a seal it should not be continuous ! (ex. a sealed bottle of pop continuously ! bubbling means it’s leaking!) • A straight catheter is to a foley catheter as a thoracentesis is to a chest tube.! - in-&-out vs. continuous secured! - thoracentesis -> also helps re-establish neg. ! pressure (in-&-out chest tube)! - higher risk for infections are continuous Rules for Clamping Tubes: • a) Never clamp a tube for more than 15 seconds ! without a doctors order.! - so if you break the water seal -> you have 15 ! seconds to get that tube under water • b) Use rubber-tipped doubled clamps.! - the teeth of the clamp need to be covered w/ ! rubber so that you don’t puncture the tube CONGENITAL HEART DEFECTS • every congenital heart defect is either TROUBLE or NO TROUBLE (ALL BAD or NO BAD)! - either causes a lot of problems or it’s no big deal (no ! in-between defect) • memorize one word: TRouBLe Heart Defects Surgery Growth & Dev. Life Expectancy Parent’s Experiencing Going Home Hospital Stay at Birth Who Follows Your Care Shunting Cyanosis TRouBLe (95% of all heart defects) NEED surgery now to live slow, delayed short grief, stress, financial issues, lots of caregiving issues apnea monitor weeks Paediatric Cardiologist R to L! (TRouBLe) Cyanotic -> Blue! (TRouBLe) No Trouble - don’t need surgery ! right away; possibly ! need it years later if it ! causes a Trouble (but ! we don’t expect it to) normal normal regular average person issues no apnea monitor 24-48 hours Paediatrician, paediatric NP L to R Acyanotic • ex. You are teaching the parents about a heart defect:! - pick all the options that cause trouble • Hint: Boards will not give pictures of defects and ask you what they are.! - not our job, we don’t diagnose! - our role is teaching parents the implications! -> so if it’s trouble = teach them things that it’s going ! to be a lot of trouble! -> if it’s not trouble = pick the things saying it’s not ! going to be trouble • There are 40+ congenital heart defects so just remember TRouBLe (don’t memorize all of them!):! - Hint: all congenital heart defects that start w/ the ! letter T are Trouble Defects! - we don’t care about the defect, we care about what ! we’re teaching the parents • All congenital heart defect kids (trouble or no trouble) will have 2 things:! a) Murmur! - why? = because of the shunting of the blood ! (regardless of direction of shunt)! b) all have an Echocardiogram done (to find out ! what the defect is or why there’s a murmur) • 4 Defects of Tetralogy of Fallout:! - VarieD PictureS Of A RancH (or Valentines Day Pick ! Someone Out A Red Heart)! 1. VD = ventricular defect! 2. PS = pulmonary stenosis! 3. OA = overriding aorta! 4. RH = right hypertrophy • don’t have to recall these, RECOGNIZE them! - recall -> remember from nothing! - RECOGNIZE -> spot it when you see it (use the ! initials to recognize them in questions) • ONLY DEFECT where they ask you what it is INFECTIOUS DISEASE and TRANSMISSION BASED PRECAUTIONS (Isolations) • Standard • Universal • Contact! - for anything enteric = can be caught from intestine! -> fecal, oral! - C-Diff, Hep. A, Cholera, Dysentery! * things with bugs in diarrhea! * Hint for Hep A & B: Hep A -> think anus, Hep B -> ! think blood (anything from the bowel starts w/ a vowel)! - Staph infections! - RSV = respiratory syncytial virus (what babies, 1-2 ! yr. old’s get that is not dangerous to adults but can ! be fatal for them)! * transmitted by droplet BUT still put them on ! contact precautions because little kids catch it ! from touching things that other sick kids touched! - Herpes infections (includes Shingles -> Herpes ! Zoster virus even though caused by varicella)! - What’s involved in contact precautions?! -> private room is preferred (but not required)! * or 2 RSV kids in the same room! * keep RSV kid & suspected RSV separate ! because you need positive cultures (not based ! on symptoms)! -> NO: mask, eye/face shield (unless for universal), ! special filter mask, PT mask, neg. air flow! -> YES: gloves, gown, hand-washing, special ! supplies & dedicated equipment (includes toys)! ** disposable supply vs. dedicated equipment:! - thermometer cover - BP cuff that stays in room • Droplet! - for bugs that travel 3 feet on large particles due to ! sneezing/coughing! - all meningitis! * cultured through lumbar puncture! - H Flu (haemophilus influenza B) -> commonly ! causes epiglotitis! * never stick something down throat because it will ! cause obstruction! - What’s involved in droplet precautions?! -> private room is preferred (but not required)! * on boards select private! * can also cohort based on positive cultures! -> NO: gown, eye/face shield, special filter mask, ! neg. air flow! -> YES: mask, gloves, hand-washing, PT worn ! mask (when leaving room), disposable supplies ! & dedicated equipment • Airborne! - M-M-R; TB; varicella (chicken pox)! - What’s involved in airborne precautions?! -> private room is required! * unless co-horting! -> NO: gown (mostly for contact), eye/face shields! -> YES: mask, gloves, hand-washing, special-filter ! mask ONLY for TB, PT mask for leaving room ! (but really shouldn’t be leaving), neg. air flow! ** disposable supplies & dedicated equipment is a ! good thing but not really as essential as in the ! other 2 (can let this one slide) ! -> TB: technically transmitted via droplet BUT put ! on airborne • PPE = Personal Protective Equipment! - boards like to test how you put on or take off! - always take it off in alphabetical order! -> ex. gloves, goggles, gown, mask! - putting on is reverse alphabetically for the ‘g’s’ & ! mask comes 2nd! -> gown, mask, goggles, gloves