S1 heart sounds marks the closure of what valves and marks the beginning of:
AV valves; marks the beginning of systole
S2 heart sounds marks the closure of what valves and marks the beginning of:
semilunar valves; beginning of diastole
S2 heart sounds can be louder when what is present?
a PE
S3 is an abnormal heart sound- what does it indicate
blood flowing into a dilated ventricle; associated with heart failure. can also be caused by pulmonary hypertension/cor pulmonale/ and mitral,aortic,tripcuspid insufficiency
Heart sounds and location:
APETM:
Aortic valve: Second intercostal space, right sternal border
Pulmonic valve: Second intercostal space, left sternal border
Erb’s point: Third intercostal space, left sternal border
Tricuspid valve: Fourth intercostal space, left sternal border
Mitral valve: Fifth intercostal space, midclavicular line
S4 heart sounds
caused by atrial contraction into a noncompliant vessel/hypertrophied // can be caused by aortic stenosis
pulse pressure =
what is the normal value
systolic - diastolic
40-60mHg
widening in pulse pressure what should you be thinking?
example: 100/38; thinking vasodilation! think drop in SVR, sepsis!!
narrowing in pulse pressure, what should you be thinking
example: 100/78
think hypovolemia or decrease in CO
systolic murmurs are:
you should ask yourself which valves are open and closed during systole:
open: aortic and pulmonic therefore; you have aortic and pulmonic stenOsis
closed: mitral/tricuspid and therefore they are insufficient
diastolic murmers?
which valves are closed during diastole?
aortic and pulmonic so aortic and pulmonic insufficiency
open during diastole?
mitral and tricuspid stenosis
unstable angina:
chest pain that may be relieved by nitro, ST depression, T wave inversion, trops are -
NSTEMI
trops are +; st depression and t wave inversion with unrelenting chest pain
STEMI
trops +; st elevation in two or more contiguous leads, and unrelenting chest pain
variant /prinzmetal’s angina
transient st elevation but eventually subsides, trops -, chest pain relieved by nitro, can happen because of coronary artery spasm and sometimes because of cocaine/etoh/nicotine
what do when a patient has chest pain?
EKG! categorize.. then
aspirin, anticoagulations (heparin, enoxaparin), antiplatelets (plavix), beta blockers, pain relief (morphine, nitro), labs!!
Treatment of STEMI
RE PERFUSION!!! IS THE GOAL
PCI and fibrinolytic therapy (tnk, alteplace, urokinase, tpa)
MOA of fibrinolytics
so you have examples such as tpa, tnk, alteplase
they essentially turn plasminogen –> plasmin —> which cleaves fibrin to dissolve the clot
what to monitor for patients post PCI?
bleeding at the sheath site, vasovagaling during the sheath removal (fluids, atropine), monitor for reocclusion, bleeding retroperitoneally (sudden hypotension and lower back pain)
Tx of NSTEMI
non emergent, can go to cath lab for diagnostic purposes, can also treat with same meds at STEMI or can start GP 2b/3a meds if chest pain is unresolved
Peripheral artery disease
6 p’s
pulse
pallor
pulseless
poikilothermia
pain
parasthesia
normal ankle brachial index is >0.90
make sure to do what in patients with PAD?
do NOT reverse trend them, and do NOT elevate the legs, it will cause lack of perfusion to the legs
what is bnp?
BNP is released by the ventricle when their is stress and it attempts to dilate or when the right ventricle is under stress
talk about systolic heart failure
happens when ventricles are dilated; causes a decrease in stroke volume and less inotropy
