Cardiac Tamponade

This has nothing to do with tampons in the heart ok! Just an FYI.

When blood or fluid accumulate in the sac which surrounds the heart it exerts pressure against the heart, making it harder for the heart to pump. As you can imagine, if the ventricles cannot fill fully or contract effectively then cardiac output decreases. Decrease cardiac output is not good news!

So how do you know if someone has this?

Well the symptoms are nothing unusual: chest pain, restlessness, quick shallow breathing, palpitations, pallor, tachycardia, weak peripheral pulses, pulsus paradoxical, distended neck veins, low BP… (do these all sound a little familiar? MI anyone?) Well causes of cardiac tamponade can be MI, Dissecting aortic aneurysm (thoracic), end-stage lung cancer, heart surgery, Pericarditis caused by bacterial or viral infections, or direct wounds to the heart.

How do we diagnose? Echocardiogram is the usual diagnostic tool, but MRI, CT, CXR or EKG can also highlight or confirm this.

Can you see the halo of fluid around the heart?

This is an emergency! The fluid must be drained to reduce damage to the myocardium and reestablish cardiac output.

Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac, the tissue that surrounds the heart. The patient will be hyperoxygenated, given fluids to maintain blood pressure. It is important to note that a pericardiocentesis may have to be repeated because cardiac tamponade can return. With fast treatment the outcome is usual good, without treatment death is immanent.

A pericardial draining tube may be placed during surgery to keep in place postop. The drainage will be measured every shift and documentation on the color, amount and consistency is very important! The tube will usually be removed slowly over the postop recovery weeks at the discretion of the cardiologist.

Hypocalcemia – Got Milk?

These test for hypocalcemia seem so random? Who in the world discovered them? Well, I guess that’s not the most important point here, the fact is: hypocalcemia is very dangerous! Think about the role calcium plays in our muscles and bones? Our heart is a muscle, so you will expect to see changes there if calcium is either low or high. So these signs Chvostek and Trousseau – I guess they are the geniuses who discovered the sx, but seriously? Could they get more complex names?! Ugh! Ok so how I remember the two, is Chvostek is “Cheek”, and Trousseau’s is “Thumb”. I find that this helps me to differentiate between the two.

Major sx to watch for is TETANY – what in the world is that you might be thinking. Well is basically means muscle spasms or twitching. So why does calcium affect muscles in this way? Calcium blocks sodium channels and stops depolarization (contraction) of nerve and muscle fibers, therefore, a lack of calcium reduces the threshold for depolarization, making the muscles jerky.

A mnemonic for hypocalceima sx:

“CATS go numb”- Convulsions, Arrhythmias, Tetany and numbness/parasthesias in hands, feet, around mouth and lips.

So is this just someone who is skipping their milk and cookies at night? No. Hypocalcemia is something seen with an array of diseases. Calcium is found in the bones, joined with other substances or free floating in the blood. Sure people with eating disorders or severe malnutirtion can have this, but it is mostly seen with those with thyroid issues. Parathyroid hormone (PTH) in a healthy person is what tightly controls calcium levels in the body. So how can PTH stop working? Well if I were assessing my patient for hypocalcemia, a crucial question would be any surgery or injury to their neck or head. Why is this? Well damage to the parathyroid in any way can inhibit the function of PTH and hypocalemia ensues. Hypoparathyroidism would be the name for this abnormality in PTH function. Surgical destruction of the parathyroid glands by parathyroidectomy, partial or total thyroidectomy, or neck dissection for head and neck cancers or any autoimmune issue can be a good indicator of why hypocalcemia is presenting.

Great Little Story to Remember Those AV Heart Blocks!

❤The Sad Story of a Struggling Marriage…❤

1st Degree AVB
Husband comes home late every night at the same time, but he
ALWAYS comes home!!!

** P waves aren’t on time but always present! Prolonged PRI

2nd Degree AVB Type 1 (Mobitz 1 or Wenckebach)
Husband comes home later and later and later until one night he
doesn’t come home at all, then the pattern starts all over again!!!

**P wave “Going, going, gone”, PRI gets longer & longer till P is dropped

2nd Degree AVB Type 2 (Mobitz 2)
Husband comes at the same time every night, but there are some
nights that he just doesn’t come home!!!

**P wave is on time but randomly drops

3rd Degree AVB (Complete)
Husband and wife are finally divorced but can’t afford to move out of
their house because of the bad economy. As a result, they are still
living under the same roof, but leading two separate lives!!! It
appears as if they’re still married, but they’re not! There is no
communication between them!!!

** P waves, PRI are not in sync with Ventricular activity (QRS) and its a hot mess!

EKG Time: I never see U waves?

Have you been diligently looking through EKG strips on your Telemetry unit trying to find a u wave? But they taught you in school it was apart of the EKG complex right? Well yes, but they are not seen all the time, which isn’t a bad thing, in fact it doesn’t really matter that much. We don’t talk about U waves very often because there isn’t really much to say, there are usually other “cardinal signs”, where a U wave can confirm something we can already see. Could be classified as last phase of ventricular repolarization or endocardial repolarization, but at the end of the day, we don’t really understand it fully though there are some things you should know about U waves:

• U waves follow T waves and should be about half the height of the T wave.
• The U wave should be less than 2 mm (2 tiny boxes on the EKG strip).
• They are mostly seen or more clearly seen, in sinus bradycardia, but if you can’t see them it’s ok!
• Best seen in leads V2, V3
• They can often interfere with the measurement of the QT intervals.

So you’ve found a EKG strip with some really cool U waves, you still need to know what the changes mean. The changes seen in U Waves (either prominent upright or depressed/inverted) are usually correlating to some other clearly visible change in the EKG (T waves changes, PR intervals or ST seg. changes). So what are some changes you should know about?

Inverted U waves are very myocardial focused. They usually mean trouble. Ischemic heart disease (often indicating left main or LAD disease) is one of a few serious readings that can come from a severely inverted U wave; Myocardial infarction (in leads with pathologic Q waves) and during a angina attack (acute ischemia or exercise-induced ischemia) they can also be present.

Upright waves (prominent ones that is) can mean Hypokalemia (remember the triad: ST segment depression, low amplitude T waves, and prominent U waves). There are times in pathological cases where the T and U wave can merge together to create a large wave, it makes it very tricky to know if it is a very large elevated T or a merge, look at the full picture, does this patient have a CNS disease or disease process going on? Then most likely it is a merge. Lastly, drugs. We all know that drugs interfere with all sorts of things, so what drugs could be messing with your U waves? Quinidine and other type 1A antiarrhythmics. Any drug that is acting on the heart can have adverse effects, but don’t forget to think about antipsychotics too! So keep this in mind when reading your EKG. Although you are focusing on a map of the heart, keep in mind that this is a patient, and every patient has a physiological story. The map you are looking at can tell you a snapshot of it’s current mapping system, but there are always other factors to consider.

Related articles

• EKG Time! (thernhangout.wordpress.com)

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Blood Transfusion – Gone Wrong! Know the different reactions so you can respond appropriately to your patient!

Whatever the reaction ALWAYS remember to STOP the transfusion!

Usually all blood products and tubing must be placed in a red biohazard bag and be sent immediately to the lab for testing. *Follow facility policies & procedures

EKG Time!

EKG TIME! (For basic understanding)

Ok so for many the EKG is a weird and wonderful map of squiggles, but actually each little squiggle is very important in translating the conduction of the heart. From your A&P course you should know that the normal conduction of the heart starts in the SA node in the Right Atrium, it travels to the AV node in the wall of the right atrium (middle of the heart), then through the Bundle of His/Left & Right Bundle Branches and down through the Purkinje fibers. The EKG is basically a map of that scenario. Imagine that you are in a car in San Antonio (SA node), you need to drive to Aventura (AV node), then you go through the spaghetti junction (Bundle of His) while heading to Pittsburg (Purkinje fibers) – if you were to use Google maps, you would have the route highlighted out on the roads you have to take, right? Well that is basically what an EKG is! It is the highlighted route the conduction took through the heart.

I hope that has given you a little clarity on those squiggly lines, haha!

Now what does the map tell us?

As you can see we use letters to signify different areas of the squiggle. You can see that P is a little bump at the beginning. This is showing us that the atria of the heart are depolarizing (another fancy word for compress or pump). The atria is pushing the blood into the ventricles. P shows that the car has left the SA node in the Right Atrium and is traveling to the AV node in the middle of the heart. From P to Q (called PR complex),  the car then leaves the AV node and travels down through the Bundle of His. One the car travels out from the Bundle of His down the Bundle Branches, through the Purkinje fibers and the rest of the heart so a QRS complex occurs. The QRS shows that the ventricles have received all the blood from the atria and pumps it back out to lungs (right V) and aorta (left V). And with that you have just witnessed a heartbeat.

Well what about the leftover squiggles…

So between the S and the T (called the ST segment), we see the heart recovering from the heartbeat, otherwise known as Ventricular REpolarization. Think about clenching your fist really hard and then relaxing, that is in essence what the heart is doing. The ST segment is very important to monitor on an EKG strip because if you are looking for something pathological, such as an MI, you might just find it here with ST segment elevation. This would mean the patient would be diagnosed as having a STEMI. We could continue this further, but we’ll save the pathological changes for another time.

So following the T wave, the heart is now ready to complete another beat! We have come full circle!

I hope you found this helpful, it is purely for basic understanding, EKG’s can be much more in depth! My best advice is so search YouTube for videos, as visualizing this is the best way to learn what it going on inside the heart!

Good Resources:

http://www.youtube.com/watch?v=7b98JcGIGyE

http://handwrittentutorials.com/

Rapid Interpretation of EKG’s 6th Ed. – Dale Durbin (really good book)