Hey everyone it's sarah thredson our RN comm and in this video i want to be going over

myocardial infarction this video is part 1 of a part 2 series and what I want to be covering is the
path of complications or signs and symptoms and how its diagnosed and in part 2 I'm going to be
covering the nursing interventions and the medications used to treat in mine and as always over
here on the side or in the description below You can access the quiz the notes and the other
videos that are in the cardiovascular NCLEX review so let's get started first let's start out talking
about what is the definition of a myocardial infarction also refer to some time as an MI or a heart
attack it is where there has been limited blood supply to the myocardial tissue that causes it to die
or become necrotic or necrosis and some causes of this what causes it the most common cause is
Blockage in a coronary artery due to coronary artery disease and we talked about this in depth in
the in CLECs review about CA D and if you want to watch that a card should be popping up so
you can access that another cause is a coronary spasm and this can be from drug use like cocaine
or the patient has uncontrolled hypertension and what happens with this is that the coronary
artery spasms it constricts so these little arteries on the heart and what Happens is when you have
that constriction you have no blood supply going to that heart muscle so that muscle is deprived
of all that rich oxygenated blood and it starts to die another cause is damage to the artery due to a
coronary artery dissection and what this is is that you have your artery it's made up of different
layers and there is a tear in the inner layer of the artery the Tunica intima and what happens is
you have this tear and Blood Starts leak and it links into the tunica media and this causes think of
it like a little bulge and limits the size of the lumen of the artery so whenever you have that you
have stricted blood flow restricted blood flow go into that heart muscle and this can happen in
young women who are young and active its most common type and it happens spontaneously
now let's look at the anatomy and the pathophysiology of how this happens I'm going to walk
you Through a little bit later of what happens minute hour days and see what happens and how
this heart tissue was nine okay so first let's go over the anatomy of the coronary arteries in this
drawing here you will see the right coronary artery and the left coronary artery and these two
coronary arteries branch off from the aorta which has just received rich oxygenated blood from
the lungs and the job of these coronary arteries is to Supply the heart muscle with fresh blood so
we can work appropriately and notice it sets right on top of the tissue now in this drawing I
wanted you to see where each coronary artery sets in relation to the atriums and the septum and
the ventricles because if you get blockages in these specific arteries it's going to cause problems
to either the left atrium the ventricle or the septum and you're going to have damage there
because you're going to get a Necrotic tissue so whenever you're learning this it's really
important you remember wet which artery supplies what so let's go over that real fast okay your
right coronary artery comes right off through here and notice where this whole runt coronary
artery is setting it branches off into these little branches which we'll talk about here in a second
but it supplies your right atrium and the right ventricle here is your right atrium and here is your
right ventricle Next you will have the right marginal artery and this supplies your right ventricle
and your septum and you see it right here it's branching off here's your right ventricle and your
septum then we have our left coronary artery and over on the other side of the heart because this
right here is our anterior view the left cornor coronary artery comes out and that's why you see an
outline these two right here the posterior descending because these are On the other side of the
heart but I wanted you to be able to see them in this view and the left coronary artery as we said
supplies the left side of the heart but it branches off into little areas and it branches off we have
the left circumflex artery circum means a round so this artery actually comes around the heart in
this area and notice where it says it supplies the left atrium and the left ventricle then you have
the el-ad the left anterior Descending artery comes down through here and this supplies a lot of
areas of the heart it supplies the right ventricle the left ventricle notice how it's branching out
over here and your septum now let's remember some things about the led the LED is the most
common sight of blockages in patients and blockages in your left coronary artery especially the
led can cause the worse damage from amma cardial important because of the damage to the
anterior Wall of the heart which we'll be going over the different anterior lateral parts of the heart
a little bit later when we talk about EKGs and why why does it do this well and heart failure we
learned that our left ventricle is the biggest area for pumping action to get our pumping to pump
our blood so if it gets affected you have an anterior wall mi your L ad causes a lot of damage
here you will get ventricular felt left ventricular failure over here so that Whenever this happens
you get a lot of damage in the heart whenever you have a blockage especially in your Li D and if
it happens before where a branch happens quickly let's review how a coronary artery can actually
become blocked now remember coronary artery disease is the number one cause of why you
have a blocked artery also you can have coronary spasm or dissection of the artery but let's look
at how it builds up over time with coronary artery Disease so here you have a healthy coronary
artery you have blood flowing through it and you have a little bit of LDL which is your bad
cholesterol now over time this happens the what happens is that maybe the patient has as factors
such as they're a smoker which is caused damage to this artery or they have high cholesterol or
they're they have uncontrolled hypertension what happens is that this artery becomes damaged
when it becomes damaged your LDL Likes to stick into this artery wall and over time it grows as
you can see here whenever it grows it limits blood supply now some of these plaques that's
turned into a plaque can rupture vulnerable plaques and whenever it ruptures as you see here it
spills its contents into the blood but the body sees that hey we have damage to our artery wall
we've got to fix it so if think nobody thinks it's helping but in reality it's going to call us a major
problem so it sends all Those platelets there to go and to fix that artery wall so they come and
they aggregate which is represented in this blue area right here and what happens I thought I was
fixing the artery wall but it actually completely stopped blood flow to that heart muscle those
heart cells and those cells die quickly and when this happens my cardial infarction happens and
you start getting the following complications when the muscle is a hundred percent block there's
no Nutrients going to those cells those cells will die and it is irreversible after approximately 30
minutes so as the saying goes time is muscle we've got to get in there fast as healthcare providers
try to save as many of these heart cells we can to prevent as much damage as possible and when
these cells die they cannot be replaced they are gone forever now early signs we'll talk about this
whenever there's a blockage those heart Cells cells start to die there are no physical changes to
the heart yet until about six to eight hours however when those myocytes die they start to release
some things that lets us know whenever we go in and draw blood that hey there's an injury to the
heart I'll talk a lot about this whenever we're going over nassim part but I'm just going to hit on
the highlights okay so whenever these micelles myocytes die my Oh glob Yulin Is released one
hour post-injury and it's an early marker however it's not too specific though we like to look at
troponin levels this is one of the gold sanders that we look at in the healthcare field there
Drammen sets usually every six hours times three depends on how the physician orders them and
it is released two to four hours post-injury another thing is ck-mb and it is released four to six
hours after injury Now you also start to see EKG changes early on which we'll talk a little bit
later about like ST segment elevation or depression t-wave inversion or it's hyper acute now later
on about 24 hours to 36 hours later inflammation starts to set in and neutrophils come onto the
scene at the side of injury where that damaged tissue is a neutrophils start to come however even
though they're coming there to do their job it can cause complication the patient is Definitely at
risk for pericarditis talk about this in in clicks review this is where all of a sudden your patient
might start complaining of pain whenever they're coughing or lying down on their back it's
relieved when they're leaning forward and on auscultation of the heart sounds you may hear a
harsh grating sandpaper noise called a pericardial friction rub and this is one of the signs and
symptoms of pericarditis also the patient is a huge risk risk for Going into cardiogenic shock
you've got some pump failure going on and also lot of times in patients who've had a myocardial
infarction you are going to see arrhythmias like atrial and ventricular arrhythmias and AV blocks
then ten days afterwards at that site of injury the tissue will start to experience granulation due to
the microphages coming on the scene and what are they these they are white blood cells that
Come to clean up the dead cells however whenever they come on the scene just like neutrophils
they're going to cause and they increase the chances of complication the complication they
increase is because whenever they're coming in to clean up that side they cause the tissue to
become weak and unstable so there's a risk of cardiac rupture then within two months there is
scarring the last phase of healing you will have scarring which will affect the Size of the heart
and the function do the increase collagen and other side other complications that a patient may
have after an MI or heart failure depression or ventricular aneurysm so what are the typical signs
and symptoms of a myocardial infarction that you need to be watching out as the nurse okay to
help us remember let's remember the mnemonic crushing Y crushing because a lot of times
whenever patients are having an mi they will say it's like Crushing chest pain that's one of the big
things that pop out I used to remember crushing okay so si for chest pain this chest pain will be
described as intense and heavy very severe are four radiating chest pain this chest pain will
normally be heavy and intense but it will radiate to the left arm the jaw or the back that's a
telltale sign if they tell you it's radiating you the chest pain is unrelieved by nitroglycerin or
arresting s sweating it Will be a cold sweat H for hard to breathe have shortness of breath just
because of the intensity of the pain literally taking their breath away I for they may have an
increased heart rate or blood pressure which is going to make the chest pain even more intense or
an irregular heart rate in for nausea and vomiting and G they are going to be absolutely anxious
and scared and as a nurse with patients who have actually experienced this in front of me I can
Tell you that I have seen this and that this is really real and it really happens now some things
you need to take into consideration women women for some reason in a little bit differently with
chest pain or their signs and symptoms of myocardial infarction so if you are educating patients
the signs and symptoms take this into consideration because some women may not have that
typical heaviness on their chest but They feel short of breath to have pain in the lower part of
their chest and they feel really extremely fatigued and they'll just play it off like I think I have an
illness like a flu I've had women patients who actually thought they came in they were having a
myocardial infarction and it turns out that they thought that they had had the flu so they had put
off coming in because I just thought they were sick so educate women that this could be a sign
also Patients who are diabetic and a silent mi this is where they don't have any pain at all they
just don't feel good comes in their EKG shows that they've had one and the reason is due to
diabetic neuropathy where those nerves have been damaged that feel pain in the heart so they had
a heart attack but they didn't feel it because those nerves I would pick up that pain normally or
damaged now let's look at the diagnostic tools used to diagnose a myocardial Infarction that may
be ordered by the physician as the nurse your role will be collecting these for instance the cardiac
markers or educating a patient about them or just knowing what to expect whenever a patient
does have an MI so let's review these okay cardiac markers as we talked about in the path up are
those myocytes release these markers that helps us to determine hey there's been injury from a
possible myocardial Infarction so the first thing let's talk about our troponin this is the most
regarded as of right now in the hospital setting in detecting a ma cardial and marching along with
an EKG this is a protein released from the heart muscle when injured from an mi they are
typically drawn in a series a lot of physicians order them every six hours times three-fifths it can
vary depending on your physician's preference so your job as a nurse it's very important you
Know when the first repentant level was drawn and make sure that those necks and levels get
drawn and you're going to be watching those lab results come into your computer system and
monitor them if they're elevating if they are elevating you need to notify the doctor immediately
so they can order whatever needs to be done to further evaluate this next is myoglobin this is
released from the myocytes again and it is an Early marker used for early detection but one thing
with this is that it's not very specific to the heart so you need further tests to evaluate it and it's
released one hour after injury it's one of our all the markers it's one that's released the earliest
next CK this is another test that may be ordered and it's a protein which is released whenever
there is muscle damage however it's not just specific to the cardiac it could it could represent
skeletal muscle As well so the physician will need to order to further evaluate it to see if it is
heart specific the CK M B and this elevates four to six hours after injury but again most regarded
our troponin levels but you will probably see these ordered as well as cardiac enzymes okay
other tools that may be ordered by the physician that you just need to know be familiar with as
the nurse is an echocardiogram what is this this is an ultrasound of the heart to see if There's any
damage to the heart muscle another thing a heart calf this is where they go in either in the
femoral artery or the radial depending on the position and they inject a dye into the coronary
arteries and this died after they injected they take an x-ray and they look in these arteries to see if
there's any blockages if there are blockages where are they located is there any damage that's
been done to the heart and can they possibly put a stent in there And open up the artery to start
replenishing that heart muscle with some more blood another thing that may be ordered is a
stress test with myocardial perfusion imaging also called mpi this assesses the heart's response to
exercise they can do it with a chemical or on a treadmill and they take imaging they do that and it
evaluates the heart muscle how that blood flow is getting to the heart muscle with imaging
another tool ordered is an EKG anytime a patient Is having chest pain comes into the yard they're
going to get an EKG so you need to be really familiar with this as the nurse and a water pause
fiddles are set up where there's a physician protocol if the patient anytime they're having chest
pain you obtain an EKG either you will obtain a your EKG tech if you have one or a nursing
assistant that has been trained in this so what you will be doing after you obtain it is that you're
going to look at the EKG and you are Going to assess for any changes if you see any changes
you need to notify the physician immediately and what's really important is that you compare
your EKG that you just got to previous EKGs as the patient has had in their chart and on
telemetry strips and you want to know what areas in the EKG reflect certain areas of the heart
and how to read it so let me go over that with you real fast here is a drawing of a basic 12 lead
EKG at each of these little areas represent Different views of the heart and as a nurse what you're
going to be doing is you're going to be looking in these specific areas for any EKG changes what
you're specifically looking for is any ST segment elevation or depression and you're going to be
looking at your T waves are they hyper Q are they inverted and you're going to be looking for
any pathological Q waves as well so real fast let's go over what each part of this EKG represents
which view of the Heart of looking at and what coronary arteries are probably being affected if
you've seen changes in that area okay the lateral view is represented in the purple this is seen in
lead one AVL v5 and v6 and the lateral view of your heart right here on this diagram is about
right here now if you notice from where we covered in the beginning what's in this lateral view
what area of the heart is being but what corny arteries are feeding the Lateral lateral part of the
heart your circumflex and your led your left anterior descending so if you're seeing EKG changes
v v e6 AVL and leave one probably may have a blockage in your circumflex and your left hand
harrier descending now inferior this is represented in to lead to lead three and a VF this is
represented in the green the inferior part of your heart is about in this area right here and if you're
seeing EKG changes in these areas right Here in the green you may have a blockage somewhere
throughout your right coronary artery now septal this is represented in v1 and v2 and it's where
your interventricular septum is located and notice what is feeding this area of the heart your
septal area mainly your el-ad your left anterior descending so if you're seeing changes there
probably have a blockage there anterior view of your heart is represented with v3 and v4 and this
is About right here in this area and that again is supplied by your el-ad your left anterior
descending and it's represented in those two areas right there and just again to recap remember
whenever I was talking about if you have damage and your el-ad you're going to have a lot of
damage on this and here on this well your anterior side and in your heart and notice where a lot
of your led is feeding your heart muscle at now let's look at the specific EKG changes That you
were looking for as the nurse first let's go over what a basic pqrst complex should look like okay
first you have this red line this is your isoelectric line certain things should fall above and certain
things should fall a little bit below and that's a big thing you're looking for whenever you're
looking for these elevations and depression so here you this little bump you have a P way then
you have just a little smidge of a dip which is your Q And you have at all our way then a small
little dip yes then you have your ST segment this extends from s to T so that right here this is the
big part we are looking for whenever we're looking for changes so not notice it's nice and flat it's
on the isoelectric line and then you have a little bump of the T wave it's nice and rounded not too
tall it's not flipped so that's perfect we like that now ST segment elevation we don't like notice
Here you have your P wave you have your Q then you have your R then all of a sudden
remember your ass over here it's dipped and then it goes straight and then you have your bump
it's not this is elevated your isoelectric line would be right here and it's way above the isoelectric
line so this is ST elevation and you see this patient having chest pain all that good stuff it's
representing injury to the cardiac muscle another thing you need to be Looking for as well an ST
segment depression they may have either or ST segment depression this is where there's your
peak QR and then ST notice just it's supposed to be on isoelectric line nice and straight it went
way below the isoelectric line and then you have your T wave so this is ST segment depression
and this represents ischemia next another thing you may see that you also need to be looking for
is those hyper acute T waves this is different remember In the hyperkalemia videos we talked
about tall T waves for hyperkalemia well this is a little bit different these waves are going to be
tall they're not going to be pointed like how in hyperkalemia they're gonna be nice and round and
tall so if you see this and the patients complaining of chest pain you got some ischemia going on
not good because that's your T wave in there so pqrs and then nice hypercute t way or you need
be looking for some inverted T Waves notice our T wave is absolutely flipped underneath the
isoelectric line so if you see that patient having chest pain ischemia not good then you may have
a pathological Q wave you really got to pay attention to this Q wave it's just a little area and you
got to you're you need to take a lot of practice and looking at this but this could represent a
current or prior an old infarction and I want to show you a Normal one here where the arrow is
pointing that is a normal cue way but just barely dips below the isoelectric line now you can have
different variations of this pathological cue a notice right here you don't have a dip at all it's the
key wave it's literally opps and it's not even there so that could be one or your cue wave can go
way below that isoelectric line even and then just be really long and then you have your R and
then your ST segment so Those if you see those that can represent a current or an old infarct ssin
okay so that was part 1 of myocardial infarction now be sure to check out part 2 to learn about
the nursing interventions and medications used to treat this condition and thank you so much for
watching and please consider subscribing to this YouTube channel