Cardiac intensive care

CardiacIntensive Care......Page 2
Copyright
......Page 3
Dedication
......Page 4
Foreword......Page 5
Preface......Page 6
Contributors......Page 7
Focus on Resuscitation......Page 18
Shift in Paradigms—Prevention of Cardiac Arrest......Page 19
Critical Care in the Coronary Care Unit......Page 20
Nursing and Clinician Training Requirements......Page 22
Technology Needs in Today's Coronary Care Unit......Page 23
Conclusion......Page 24
References......Page 25
Western Biomedical Ethics......Page 26
Beneficence......Page 27
Justice......Page 28
Casuistry......Page 29
Communication......Page 30
Determining Patients’ Values and Preferences......Page 31
Patients Lacking Decision-Making Capacity......Page 32
Patient Self-Determination Act......Page 33
Withholding and Withdrawing Basic Life Support......Page 34
Withholding Advanced Life Support......Page 35
Withdrawing Advanced Life Support......Page 36
Euthanasia and Assisted Suicide......Page 37
Cross-Cultural Conflict......Page 38
References......Page 39
Diagnoses......Page 42
Chest Pain and Acute Coronary Syndromes, and Acute Myocardial Infarction......Page 43
Heart Failure......Page 45
Arrhythmias......Page 46
Other Indications for Intra-aortic Balloon Pump......Page 47
Aortic Disease......Page 48
Elderly......Page 49
References......Page 50
Temperature......Page 53
Respiration......Page 54
Pulse......Page 55
Blood Pressure......Page 56
Jugular Venous Pulse and Abdominojugular Reflux......Page 57
Chest and Lung Examination......Page 58
Thorax and Heart Examination......Page 59
Auscultation of the Heart......Page 60
Heart Murmurs: Static and Dynamic Auscultation......Page 61
Abdominal Examination......Page 63
Neurologic Examination......Page 65
Musculoskeletal and Integument Examination......Page 66
References......Page 67
Total Pulmonary Blood Flow and Oxygen Exchange......Page 68
Pulmonary Transit Time......Page 69
Distribution of Blood Flow within the Lungs......Page 70
Ventricular Function and Lung Disease......Page 72
Cardiovascular Function and Systemic Gas Exchange......Page 73
References......Page 76
Reflex Control of Cardiac Output......Page 78
Left Ventricular Performance......Page 79
Effect of Changes in Afterload......Page 80
Diastolic Dysfunction......Page 81
Dilated Cardiomyopathy......Page 82
References......Page 83
Vessel Wall and Local Control of Coronary Blood Flow......Page 86
Pathophysiology......Page 87
Myocardial Ischemia......Page 88
References......Page 89
Fatty Streak......Page 90
Progression of Atherosclerosis......Page 93
Chronic Endothelial Injury......Page 94
Recurrent Thrombosis......Page 95
Inflammation......Page 96
Circumferential Bending......Page 97
Platelet Adherence......Page 98
Fibrinolysis......Page 99
Residual Thrombosis......Page 100
References......Page 101
Platelets......Page 104
Coagulation Proteins......Page 105
Step 1: Initiation of Coagulation on Tissue Factor–Bearing Cells......Page 106
Step 2: Amplification of the Procoagulant Signal by Thrombin Generated on the Tissue Factor–Bearing Cell......Page 107
Step 3: Propagation of Thrombin Generation on the Platelet Surface......Page 108
Endothelial Antithrombotic Mechanisms......Page 109
Excessive Fibrinolysis......Page 110
What Happens after the Bleeding Stops......Page 111
References......Page 112
History......Page 113
Diagnosis......Page 114
Prognosis......Page 115
Novel Cardiac Markers......Page 116
Physical Examination......Page 117
Electrocardiogram......Page 118
Conclusion......Page 119
References......Page 120
Inferior Myocardial Infarction......Page 122
Diagnosis in Bundle Branch Block......Page 123
References......Page 124
CORONARY THROMBOSIS AND THE PATHOGENESIS OF ACUTE MYOCARDIAL INFARCTION......Page 126
CORONARY THROMBOLYTIC AGENTS: PROVING THE VALUE OF REPERFUSION......Page 127
Urokinase......Page 128
Tissue Plasminogen Activator......Page 129
MORTALITY BENEFIT OF PHARMACOLOGIC REPERFUSION: CLINICAL TRIALS OF CORONARY THROMBOLYSIS......Page 130
Patency Trials......Page 131
Left Ventricular Function and Pharmacologic Induction of Reperfusion......Page 132
Pivotal Placebo-Controlled Trials......Page 134
Fibrinolysis, Reperfusion, and the Importance of Early Treatment......Page 135
Platelet-Targeted Conjunctive Therapy......Page 136
Alternatives to Unfractionated Heparin......Page 137
INTRACRANIAL HEMORRHAGE AND STROKE......Page 138
PATIENT SELECTION, COMPLICATIONS, AND CONSIDERATIONS PERTINENT TO SPECIFIC GROUPS......Page 140
Patients with Congestive Heart Failure or Cardiogenic Shock......Page 141
Treatment of Hemorrhage......Page 142
Feasibility of Early Percutaneous Coronary Intervention for Treatment of ST Segment Elevation Myocardial Infarction......Page 143
PRIMARY PERCUTANEOUS CORONARY INTERVENTION FOR TREATMENT OF ST SEGMENT ELEVATION MYOCARDIAL INFARCTION......Page 144
EFFORTS TO OVERCOME LIMITATIONS DISCOVERED IN EARLY TRIALS OF PRIMARY PERCUTANEOUS CORONARY INTERVENTION......Page 145
Platelet Adenosine Diphosphate Receptor Inhibitors......Page 146
Direct Thrombin Inhibitors and Pentasaccharides......Page 147
Rescue Percutaneous Coronary Intervention......Page 148
Consolidation Percutaneous Coronary Intervention......Page 149
Facilitated Percutaneous Coronary Intervention and ASSENT-4......Page 150
Cardiogenic Shock......Page 151
CONCLUSION......Page 152
References......Page 154
CHAPTER 13
Adjunctive Pharmacologic Therapies in Acute Myocardial Infarction......Page 161
Aspirin......Page 162
Dose, Timing, and Benefits......Page 163
Adverse Effects......Page 165
Mode of Action......Page 166
Dosing, Timing, and Benefits......Page 167
Summary of ACC/AHA Task Force Recommendations for Thienopyridines in ST Segment Elevation MyocardialInfarction......Page 168
Dosing, Timing, and Benefits......Page 169
Nitrates......Page 171
Dosing, Timing, and Benefits......Page 172
Mode of Action......Page 173
Dosing, Timing, and Benefits......Page 175
Summary of ACC/AHA Task Force Recommendations for Angiotensin-Converting Enzyme Inhibitors and OtherRenin-Angiotensin-Aldosterone System Inhibitors in ST Segment Elevation Myocardial Infarction......Page 179
Dose, Timing, and Benefits......Page 180
Summary of ACC/AHA Task Force Recommendations for Magnesium in ST Segment Elevation Myocardial Infarction......Page 181
Glycemic Control and Insulin......Page 182
Summary of ACC/AHA Task Force Recommendationsfor Lipid Management in ST Segment Elevation MyocardialInfarction......Page 183
Modes of Action......Page 184
Dosing, Timing, Benefits, and Adverse Effects......Page 185
Summary of ACC/AHA Task Force Recommendations for Secondary Prevention Using Vitamin and Dietary Supplements after ST Segment Elevation Myocardial Infarction......Page 188
References......Page 189
Calcium Antagonists......Page 199
Aspirin......Page 200
Thienopyridine Agents......Page 201
Glycoprotein IIb/IIIa Receptor Inhibitors......Page 202
Heparin......Page 206
Low-Molecular-Weight Heparins......Page 207
Statin Therapy......Page 208
References......Page 209
Biochemistry and Assays of Troponins......Page 212
Troponin and Myocardial Damage......Page 213
Direct Myocardial Damage......Page 214
Chronic Renal Insufficiency and End-Stage Renal Disease......Page 215
References......Page 216
Incidence......Page 219
Consequences......Page 220
Prevention......Page 221
Recognition......Page 222
Treatment......Page 223
References......Page 224
Epidemiology......Page 228
Pathophysiology......Page 229
Clinical Presentation......Page 230
Pharmacologic Support......Page 231
Mechanical Support......Page 234
Percutaneous Coronary Intervention......Page 236
Conclusion......Page 238
References......Page 239
Coronary Circulation and the Right Ventricle......Page 241
Clinical Presentation......Page 242
ST Segment......Page 243
Cardiovascular Magnetic Resonance Imaging......Page 244
Inotropic Support......Page 245
Complications......Page 246
References......Page 247
Diagnosis......Page 249
Mitral Regurgitation......Page 250
Diagnosis......Page 251
Management......Page 252
Clinical Features......Page 253
Dynamic Left Ventricular Outflow Tract Obstruction Complicating Acute Myocardial Infarction......Page 254
References......Page 255
Atrial Arrhythmias......Page 257
Atrial Fibrillation and Flutter......Page 258
Ventricular Arrhythmias......Page 259
Ventricular Tachycardia......Page 261
Ventricular Fibrillation......Page 262
Ventricular Tachycardia......Page 263
Ventricular Tachycardia......Page 264
References......Page 265
Below the Atrioventricular Node......Page 267
Inferior Wall Myocardial Infarction versus Anterior 
Wall Myocardial Infarction......Page 268
Standard Indications......Page 269
References......Page 270
Target Lesion Anatomic Factors......Page 271
Mechanistic Categories......Page 273
Complex Coronary Anatomy......Page 274
Devices......Page 275
Other Mechanical Measures......Page 276
Mechanical Measures......Page 277
Distal Embolization......Page 278
Stent Infection......Page 279
Contrast-induced Nephrotoxicity......Page 280
References......Page 281
Aortic Valvuloplasty......Page 282
Arterial Access and Sheath Removal Techniques......Page 286
Retroperitoneal Hematoma......Page 287
Vascular Perforation......Page 288
Thrombotic Complications......Page 289
References......Page 290
Pulmonary Edema......Page 291
Afterload......Page 292
Left Ventricular Pressure-Volume Relationships......Page 294
Hemodynamic Examples of Acute Heart Failure Syndromes......Page 295
Clinical Presentation of Acute Heart Failure......Page 296
Hypotensive Decompensation......Page 297
Acute Heart Failure with Severe Pulmonary Edema......Page 298
Diagnosis......Page 299
Differentiating Cardiogenic from Noncardiogenic Pulmonary Edema......Page 300
Step 1: Define Clinical Severity of Acute Heart Failure......Page 301
Infections......Page 302
Vasodilators......Page 303
Nitroglycerin......Page 304
Nesiritide......Page 305
Dopamine......Page 306
Hypertensive Acute Heart Failure......Page 308
Pathologic Substrates......Page 309
Nonatherosclerotic CAD......Page 311
Hypertrophic Cardiomyopathy (HCM)......Page 312
Long QT (LQT)......Page 313
Short QT Syndrome (SQTS)......Page 315
Catecholaminergic Polymorphic VT (CPVT)......Page 316
Congenital Heart Disease......Page 317
Evaluation Of The Sca Survivor......Page 318
Pharmacologic Therapy......Page 320
Implantable Cardioverter Defibrillator (ICD)......Page 321
References......Page 323
Infection......Page 326
Thrombosis and Thromboembolism......Page 333
Failure to Capture......Page 334
Oversensing......Page 338
Undersensing......Page 342
Biventricular Pacing Systems......Page 343
Cardiac Pacing Under Specific Clinical Circumstances......Page 344
Inappropriate ICD Shock......Page 346
Electrical Storm......Page 347
Magnetic Resonance Imaging......Page 348
Ineffective ICD Therapy......Page 349
References......Page 350
SECTION IIImplantable Cardioverter Defibrillator Emergencies......Page 345
Pathophysiology......Page 355
Clinical Presentation......Page 356
Treatment......Page 357
Acute Mitral Regurgitation......Page 358
Diagnosis......Page 359
Treatment......Page 361
Etiology and Clinical Presentation......Page 362
Congestive Heart Failure......Page 363
Etiology......Page 364
Treatment......Page 365
Treatment......Page 366
Treatment......Page 367
References......Page 368
Definition......Page 371
Diagnosis......Page 372
Prognosis......Page 374
Hypertensive Encephalopathy......Page 377
Stroke......Page 378
Renal Insufficiency......Page 379
Hyperadrenergic States......Page 380
Cyanide Toxicity......Page 381
References......Page 382
Predisposing Factors......Page 384
Clinical Features......Page 385
Diagnosis......Page 386
Management......Page 388
Diagnosis......Page 390
Pathogenesis......Page 391
Management......Page 392
References......Page 393
Pericardial Syndromes in Ischemic Heart Disease......Page 396
Biomarkers......Page 397
Pericardial Effusion......Page 398
Diagnosis......Page 399
Low Pressure Cardiac Tamponade......Page 401
Constrictive Pericarditis......Page 402
References......Page 403
PHYSIOLOGY OF GAS EXCHANGE......Page 404
PATHOPHYSIOLOGY OF ACUTE RESPIRATORY FAILURE......Page 405
Clinical Assessment......Page 406
Differential Diagnosis......Page 407
Management......Page 410
Mechanical Ventilation......Page 411
References......Page 413
Definition......Page 414
Effects of Thrombolysis on Recurrent PE, Major Bleeding and Mortality......Page 415
Thrombolytic Agents......Page 416
Submassive Pulmonary Embolism......Page 417
Conclusion......Page 418
References......Page 419
Pulmonary Vascular Anatomy and Physiology......Page 421
Clinical Presentation......Page 422
Diagnostic Evaluation......Page 424
Idiopathic Pulmonary Arterial Hypertension......Page 426
CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION......Page 430
References......Page 432
CHAPTER 34 Hemodynamically Unstable Presentations of Congenital Heart Disease in Adults......Page 434
Arrhythmias......Page 435
Ventricular Tachyarrhythmias......Page 437
Heart Failure in the Adult with Congenital Heart Disease......Page 438
Etiologies of Pump Failure......Page 439
Management......Page 440
Conclusion......Page 441
References......Page 442
Pathophysiology......Page 443
Clinical Manifestations......Page 444
ß-Adrenergic Antagonists......Page 445
Digoxin......Page 446
Sodium Channel Blocking Agents......Page 447
Procainamide......Page 448
Phenytoin......Page 449
Pharmacology......Page 450
Antipsychotics (Phenothiazines, Butyrophenones, and Atypical Agents)......Page 451
Carbamazepine......Page 452
Illicit Drugs......Page 453
Pathophysiology......Page 454
References......Page 455
Management......Page 456
Hemostasis And The Coagulation Cascade......Page 459
Antithrombins—Mechanism Of Action......Page 460
Clinical Evidence......Page 461
Pharmacokinetics, Metabolism, and Administration......Page 462
Clinical Evidence......Page 463
Clinical Evidence......Page 464
References......Page 465
Antiplatelet Therapy for Unstable Angina and Non-STEMI......Page 468
Acetyl Salicylic Acid (ASA or Aspirin)......Page 469
Clopidogrel......Page 470
Ticlopidine......Page 472
Abciximab......Page 473
Eptifibatide......Page 474
Tirofiban......Page 475
ADP Receptor Antagonists......Page 476
IIb/IIIa Inhibitors and Thrombolytic Therapy......Page 478
IIb/IIIa Inhibitors and Primary PCI......Page 479
Glycoprotein IIb/IIIa inhibitors......Page 482
Aspirin......Page 481
References......Page 483
Sympathomimetic Agents......Page 486
Dobutamine......Page 487
Norepinephrine......Page 488
Inamrinone......Page 489
vasodilators......Page 490
Nitroglycerin......Page 491
Nesiritide......Page 492
References......Page 493
Mechanisms......Page 495
Response to Diuretic Administration for Acute Cardiac Decompensation......Page 496
Thiazides and Potassium-Sparing Diuretics......Page 498
Optimizing Intravenous Diuretic Response......Page 499
Diuretic-Resistant Edema......Page 500
Positive Inotropic Agents: Augmented Diuresis?......Page 501
References......Page 502
Phase 4......Page 504
SA Node and AV Node Action Potential......Page 505
Vaughan-Williams......Page 506
Class II Antiarrhythmics......Page 507
Drug Absorption......Page 508
Distribution......Page 509
Procainamide......Page 510
Lidocaine......Page 511
Class II......Page 512
Amiodarone......Page 513
Class IV......Page 515
Digoxin......Page 516
Adenosine......Page 517
References......Page 518
Site of Action and Receptor Physiology......Page 520
Cardiovascular and Hemodynamic Effects......Page 521
Side Effects, Complications, and Toxicity......Page 522
Pharmacokinetics, Pharmacodynamics, and Metabolism......Page 523
Pharmacokinetics, Pharmacodynamics, and Metabolism......Page 524
Side Effects and Toxicity......Page 525
Cardiovascular and Hemodynamic Effects......Page 526
Clinical Indications......Page 527
Clinical Indications......Page 528
References......Page 529
Nitrates......Page 532
Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers......Page 533
Interactions Affecting Elimination......Page 534
Quinidine......Page 535
Lidocaine......Page 537
Calcium Channel Blockers......Page 538
Antithrombotic and Anticoagulant DrugsAspirin......Page 540
Warfarin......Page 541
Lipid-Lowering Drugs......Page 543
References......Page 544
CHAPTER 43
Echocardiography in the CICU......Page 548
LV Aneurysm......Page 549
Apical Clot......Page 550
Exclusion of Right Ventricular (RV) Involvement......Page 551
LVOT Obstruction......Page 552
Free Wall Rupture......Page 553
Acute Mitral Regurgitation Secondary to Rupture of the Papillary Muscle......Page 554
Guidance of Placement and Monitoring of Assist Devices......Page 555
Aortic Diseases......Page 556
Infective Endocarditis......Page 557
References......Page 558
Complications......Page 560
Technique......Page 561
Indications and Contraindications......Page 562
Indications and Contraindications......Page 563
Clinical Pearls......Page 564
Clinically Relevant Anatomy......Page 565
Technique......Page 566
Technique......Page 568
Clinical Pearls......Page 570
References......Page 571
Right Heart and Pulmonary Artery Catheterization: A Historical Perspective......Page 573
The Catheter......Page 574
Catheter Insertion......Page 575
Pulmonary Artery Occluded and Wedge Pressure......Page 576
Fick Method......Page 577
Pulmonary Vascular Damage......Page 578
Indications for Pulmonary Artery Catheterization......Page 579
Acute Myocardial Infarction......Page 580
Ventricular Septal Defect......Page 581
Controversies......Page 582
References......Page 584
Physiologic Principles......Page 585
Monitoring of IABP Counterpulsation......Page 586
Placement of the IABP Is the First Step for CounterpulsationTherapy......Page 587
Clinical Efficacy and Indications......Page 588
High-Risk Percutaneous Coronary Intervention......Page 590
References......Page 591
Background......Page 594
Adverse Events......Page 595
Axial Flow Pumps......Page 596
Future Directions......Page 597
Bridge to Recovery......Page 598
References......Page 599
Stage D Identification and Candidate Selection Criteria......Page 601
Age......Page 603
Infection......Page 604
Pretransplant Patient Management......Page 605
Medical Therapy in Advanced Cardiac Failure......Page 606
Immediate Pretransplant Considerations......Page 607
Posttransplant Immunosuppression......Page 608
Posttransplant Complications that may Necessitate Intensive Care......Page 609
Future Directions......Page 611
References......Page 612
Preoxygenation (Before Induction and Intubation)......Page 613
Suction......Page 614
Airway Evaluation......Page 615
Definition of Difficult Airway......Page 616
Airway Examination Principles......Page 618
Oropharyngeal and Nasopharyngeal Airways......Page 619
Rigid Direct Laryngoscopy......Page 620
Rapid Sequence Intubation......Page 622
Unstable, Uncooperative, or Apneic Patients with Difficult Airways......Page 625
Laryngeal Mask Airway......Page 627
Rigid Bronchoscope......Page 628
Cricothyroidotomy - Percutaneous......Page 629
Blind Intubation Techniques......Page 631
Blind Nasal Intubation......Page 632
Fiberoptic Bronchoscopy......Page 633
Local Anesthesia and Vasoconstriction......Page 634
Awake Nasal Technique......Page 636
Oral Technique......Page 637
Unrecognized Esophageal Intubation......Page 638
Aspiration of Gastric Contents......Page 639
Techniques to Limit Hypotension Following Intubation......Page 640
True “Code” (Full Cardiopulmonary Arrest)......Page 641
Respiratory Failure Due to Gas Exchange Problems (Shunt)......Page 642
Valvular Heart Disease......Page 643
Asthma......Page 644
Airway Management for Cardioversion......Page 645
References......Page 646
Impact of Positive Pleural Pressure on Hemodynamics......Page 647
Oxygenation......Page 648
Delivery of Mechanical Ventilation......Page 649
Mandatory Breaths......Page 650
Initial Ventilator Settings......Page 651
Discontinuing Mechanical Ventilation......Page 652
Barotrauma and “Volutrauma”......Page 654
Acute Respiratory Distress Syndrome......Page 655
References......Page 656
Principles and Technical Aspects of Renal Replacement Therapy......Page 659
Continuous Renal Replacement Therapies (CRRT)......Page 660
Optimal Timing for Initiation of RRT......Page 661
Goals of RRT/Monitoring Parameters......Page 662
Ultrafiltration for Decompensated Heart Failure......Page 663
Conclusion......Page 664
Three Phases of Ventricular Fibrillation......Page 667
Electrical Defibrillation......Page 668
Cardiocerebral Resuscitation—A New Approach for Cardiac Arrest......Page 669
Cardiocerebral Resuscitation Improves Survival of Patients with Out-of-Hospital Cardiac Arrest......Page 670
Proper Technique of Chest Compressions......Page 671
Full Chest Wall Recoil Following Chest Compressions is Essential......Page 672
Emergency Medical Services Components of Cardiocerebral Resuscitation......Page 673
Positive Pressure Ventilations Eliminated or Delayed......Page 674
The Mechanisms of Blood Flow During Cardiac Arrest and Closed-Chest Compression......Page 675
Considerations in Resuscitation Research......Page 676
Postresuscitation Care......Page 677
Ventricular Fibrillation......Page 678
Defibrillation Energy, Current, and Voltage......Page 679
Factors Determining Transthoracic Impedance......Page 680
Who Should Be Cardioverted?......Page 681
Anticoagulation before Elective Cardioversion......Page 682
Does Electrode Type Make a Difference?......Page 683
Conclusion......Page 684
APPENDIX 1
Color Key to ACC/AHA Management Guidelines: Estimate of Certainty (Precision) of Treatment Effect......Page 687
APPENDIX 2
ACC/AHA Guidelines for Primary Percutaneous Coronary Intervention of ST Segment Elevation Acute Myocardial Infarction......Page 689
A. Anti-Ischemic and Analgesic Therapy......Page 690
B. Antiplatelet Therapy......Page 692
C. Anticoagulant Therapy......Page 693
B. Patients with Cardiac Structural Abnormalities or Remodeling Who Have Not Developed Heart Failure Symptoms (Stage B)......Page 694
C. Patients with Current or Prior Symptoms of Heart Failure (Stage C)......Page 695
D. Patients with Refractory End-Stage Heart Failure (Stage D)......Page 697
A......Page 698
B......Page 702
C......Page 703
D......Page 706
E......Page 708
F......Page 709
H......Page 710
I......Page 711
L......Page 712
M......Page 713
N......Page 714
P......Page 715
R......Page 718
S......Page 719
T......Page 720
V......Page 722
W......Page 723