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Cardiovascular and Hemodynamic

Assessment Essentials

Al Quinones, DHA, MA, RRT-NPS, RPFT, RPSGT, CCT, A-EC, FACHE

Circulatory Path Cardiac Auscultation

Systole -  S1: Closure of AV valves at the onset of systole -  Systolic murmur: Regurgitation through AV valve; Forward flow through

stenotic semilunar valve Diastole -  S2: Closure of semilunar valves at the onset of diastole -  Diastolic murmur: Regurgitation through semilunar valve; Forward flow

through stenotic AV valves

Heart Sounds

" Normal S1 S2

" https://www.youtube.com/watch?v=X0p9GqvaKDw

" Aortic Murmur " https://www.youtube.com/watch?

v=HtDzHWNYKQM " Mitral Valve Murmur " https://www.youtube.com/watch?

v=OQ9xrxDg3uc

Definition of Hemodynamic terms

" Preload – amount of blood in the ventricle before contraction: End diastolic volume – EDV determines the amount of ‘stretch’ that is

placed on the myocardial muscle – That ‘stretch’ determines the strength of the next

contraction – The strength of the contraction determines how

much blood is pumped out of the ventricle during the next systole ‘stroke volume’

– The stroke volume determines the blood pressure

" Afterload - resistance to blood flow from the ventricle; work that must be done to pump blood from the ventricle to the circulation

" Resistance determined by size of valve opening, blood viscosity and blood pressure in pulmonary or systemic circulation

" Work – is the oxygen consumed by the myocardium to overcome the resistance to flow

Alveolar Capillary

Membrane

Lets Talk More About: Normal Alveolar Capillary Membrane

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Early Pulmonary Edema Interstitial Edema Late Pulmonary Edema

Flow-directed pulmonary artery catheters

Swan-Ganz catheters can perform many functions including: 1.  Direct measurement of the right atrial pressure, right

ventricular pressure, and pulmonary arterial pressure 2.  Indirect assessment of the left atrial pressure via

measurement of the pulmonary artery occlusion pressure (also called the pulmonary capillary wedge pressure)

3.  Sampling of mixed venous blood 4.  Thermodilution analysis, which is used to calculate

hemodynamic variables such as cardiac output, pulmonary vascular resistance, and systemic vascular resistance.

Pulmonary Artery Catheter Swan Insertion " The potential sites for

insertion of Swan-Ganz catheters include:

1.  internal jugular vein 2. subclavian vein 3.  femoral vein 4. right or left brachial

veins.

Pulmonary Artery Catheter in Wedge Position Normal Chest x-ray

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MV: Cardiovascular Affects Ø Cardiovascular-Lung relationships

– Spontaneous breathing

MV: Cardiovascular Affects Ø Cardiovascular-Lung relationships

– Positive pressure ventilation

Pulmonary artery catheters for adult patients in intensive care.

Rajaram SS1, Desai NK, Kalra A, Gajera M, Cavanaugh SK, Brampton W, Young D, Harvey S, Rowan K.

" PAC is a diagnostic and haemodynamic monitoring tool but

not a therapeutic intervention. Our review concluded that use of a PAC did not alter the mortality, general ICU or hospital LOS, or cost for adult patients in intensive care. The quality of evidence was high for mortality and LOS but low for cost analysis. Efficacy studies are needed to determine if there are optimal PAC-guided management protocols, which when applied to specific patient groups in ICUs could result in benefits such as shock reversal, improved organ function and less vasopressor use. Newer, less-invasive haemodynamic monitoring tools need to be validated against PAC prior to clinical use in critically ill patients.

Left-Sided Heart Failure " Pulmonary congestion occurs

when left ventricle cannot pump well

" Dyspnea upon exertion, orthopnea, and paroxysmal nocturnal dyspnea

" Oliguria

Right-Sided Heart Failure

" Congestion of viscera and peripheral tissues when right ventricle fails

" Jugular vein distention " Dependent edema " Hepatomegaly " Ascites " Weakness, anorexia, and nausea " Weight gain

Coronary Artery Disease (CAD)

Assessment " Presentation: Unstable

angina, SOB, N/V, Diaphoresis, Lightheadedness, Syncope

" Elevated cardiac enzymes

" ST or T wave changes on 12 lead

Plan of Care " Supplemental 02

" Pain management " Antiplatelet therapy " Dysrhythmia

management " Reperfusion decision

Percutaneous coronary intervention (angioplasty) Stenting

Percutaneous coronary intervention (angioplasty) Stenting

" http://www.bing.com/videos/search?q=Percutaneous+coronary+intervention+VIDEO&FORM=VIRE1#view=detail&mid=5FC075889623DE04DC4C5FC075889623DE04DC4C

CAD, MI

STEMI " Rapid decision

regarding reperfusion strategy

" Cardiac catheterization " Fibrinolysis " Percutaneous

angioplasty/stenting " CABG

NSTEMI " Thorough examination

and risk stratification. " Search for non-coronary

causes " Stress testing if negative

cardiac enzymes " Consider adjunctive

treatment (NTG, Beta blockers, Heparin)

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Cardiac Cath

http://www.bing.com/videos/search?q=cardiac+catheterization+video+youtube&FORM=VIRE9#view=detail&mid=2D962259B9369708A3A12D962259B9369708A3A1

Where is the MI? Where is the MI? CHF

Assessments " Pleural effusion:

Increased hydrostatic pressure

" Pulmonary Edema: Productive cough with pink frothy secretions

" Dyspnea " Increased L heart preload,

decreased contractility, increased afterload

Plan of Care " Supplemental oxygen (if

hypoxemic), NPPV (refractory hypoxemia, acidosis)

" Intubation, PEEP (failed NPPV)

" Diuretic, Vasodilator, Inotrope

PHTN Assessments

" Dyspnea " Angina " Loud S2 (AV valve closure) " ECG: RV hypertrophy (R in V1 + S in V5 (or V6) 10 mm)

" CXR: Kerley B lines " Echo: RV dilation, tricuspid

regurgitation " Increased R heart preload,

JVD

Plan of Care

" Prevent hypoxemia! " Oxygen " PEEP/ CPAP " Inhaled pulmonary

Vasodilators " Lung Transplant

Kerley B Lines linear opacities seen on the chest radiograph. They are 1-2 cm long

horizontal lines which meet the pleura at right angles. They are typically seen as a ladder up the side of the lungs beginning at the costophrenic

Shock

" Hypovolemic " Cardiogenic " Distributive

- Septic - Neurogenic - Anaphylatic

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Shock

Assessments " Tachycardia,

hypotension " Dyspnea " Mental status change " Diaphoresis " Metabolic acidosis " Oliguria

Plan of Care " Avoid PPV " Adequate

oxygenation " Appropriate

intravascular volume

" Judicious PEEP