Nonpharmacological medical management of the cardiovascular/pulmonary systems (e.g., diagnostic imaging, laboratory test values, other medical tests,
surgical procedures)
Ventilation
The depth of ventilation is usually observed. A large depth needs the use of accessory muscles of inspiration. Normally, it is observed by a facial grimace and inability to talk. Normal rate is 12 breaths per minute, increased rate can be up to 18-20 breaths per minute. Extreme can be up to 30 breaths per minute.
Heart Rate
The number of pulses per minute. This is measured by taking the patient's pulse.
A pulse is usually described in terms of its rate, which is the number of heart beats per minute (bpm).
However, a person taking a pulse may also note information about the rhythm and strength of the heartbeat and whether the blood vessel feels hard or soft. An irregular rhythm, a weak pulse, or a hard blood vessel may indicate a medical condition that needs further evaluation.
The pulse rate is measured by counting the beats in a set period of time (at least 15 to 20 seconds) and multiplying that number to get the beats per minute.
When the patient exercises, has a fever, or is under stress, the heart rate usually speeds up to meet the body's increased need for oxygen and nutrients carried in the blood. As a result, your pulse rate normally varies from minute to minute.
Besides for checking a person's fitness level, a pulse rate may also be measured when the person has been resting for 10 minutes or more. That measurement is called a resting pulse rate. It is an accurate and simple assessment of the health of the heart and circulatory system.
Resting heart rate
Age or fitness level Beats per minute (bpm)
Babies up to age 1: 100––160
Children age 1 to 10: 60––140
Children age 10+ and adults: 60––100
Well-conditioned athletes: 40––60
Common problems occur in adults that have a higher than expected heart rate. Irregular rhythms (which are associated with arrhythmia) also decrease heart rate due to missed or very weak pulses. In infants it is more the low heart rate that should trigger an alarm in the therapist. On the NPTE the
infant/premature heart rate may be used in a question. The adults we need to worry about are those with high and irregular rhythms.
Heart rhythm
Taking the pulse for heart rhythm
The carotid is used in emergency situations and when we teach a patient to take their own pulse
The Axillary and Brachial is used in infants and very young children
The radial pulse is the most often used. It also best reflects general perfusion of the tissues
The dorsalis pedis is used to check the perfusion of the leg.
The ulnar, posterior tibilal and popliteal pulse is too deep to palpate, usually a Doppler is used to hear the pulse.
Take the pulse for 60 seconds. Feel for the same strength and rhythm.
The pulses are uniform In regards to strength
Rate Criteria
Regular pulse feel Regular rate Normal
All the pulses are uniform In regards to strength
Pulses are at predictable intervals
Irregular Irregular 4 or more: do not start exercise
The pulses are not uniform in regards to strength.
Depolarization coming from an abnormal area of the heart
The rate is not predictable.
Some pulses may feel too close or pulse feels that it is missing
Increasing number: If irregularities with increasing stress stop as an area of the myocardium is ischemic.
6 or more during exercise stop.
Irregular Regular If exercising, do not start or stop
exercise.
There are two or more conduction pathways across the heart.
Pulse: Taking a patient’s pulse (heart rate and rhythm)
As the heart beats, blood moves through the arteries. You can feel a throbbing (beat) in some of the arteries close to the skin surface. A normal resting pulse for an adult is 50 to 100 beats per minute, and the rhythm should be regular.
The two arteries that are easiest to find to take your pulse are:
The Radial artery, located on the palmar side of the wrist on the lateral side, and the Carotid artery, located on either side of the trachea in the neck.
To take your patient’s pulse:
Place two fingers gently on the artery. Do not use your thumb because it has its own pulse that you may feel.
Count the beats for 10 seconds and multiply times 6. Studies have found this is the most accurate.
Count the beats for 15 seconds and multiply times 4. Studies have found this is the most common and is almost as accurate.
Count the beats for 30 seconds; then double the results to get the number of beats per minute.
This is not as accurate, but also allows a longer sample that can also detect rhythm changes.
Count the beats for 60 seconds. This method is inaccurate for the determination of heart rate but the most accurate for determination of rhythm changes.
Heart rate can also be calculated from the EKG by observing the R wave to R wave distance. This may not always correspond to the pulse. The average for 1 minute is the heart rate.
Palpation of the Patient:
Palpation can give a therapist clues as to abnormalities of the heart chambers, heart rate and rhythm to systolic blood pressure and peripheral circulation. When studying this you should review how to take
blood pressure and other vital signs.
Normally these arteries are easy to palpate:
o Carotid artery o Axillary artery o Brachial artery o Radial artery o Femoral artery o Dorsalis Pedis artery
These deep arteries are more difficult and usually are examined with a Doppler:
Ulnar is palpated by first occluding the radial artery
The abdominal aorta is usually not able to be felt. If it is palpated this indicates an abdominal aortic aneurism is present
The popliteal artery
The posterior tibial artery
The dorsalis pedis when there is insufficient blood flow
Common ways of acquiring pulse
The radial pulse:
This is the most commonly taken peripheral pulse. Being located distally it reflects the pulse pressure and perfusion to the whole body.
The radial artery is palpated within the boundaries of the anatomical snuff box.
The Brachial pulse:
This pulse is commonly taken in small children. It is palpated within the antecubital fossa.
The Axillary pulse:
This is most often used in infants and is felt with palpation over the axilla.
The Apical Pulse:
This is felt or heard over the apex of the heart. (T5 under the left nipple). This best reflects the heart rate, but does not reflect profusion throughout the body.
The Carotid Pulse:
This is palpated in the neck just lateral to and below the larynx. This pulse is of the greatest pressure of all the pulses commonly taken and best reflects perfusion to the brain. Since this is the strongest pulse, patients are often taught to use it to monitor their own pulse rate.
Palpation Techniques
Study the following chart covering palpation techniques paying particular attention to the implications of the finding and what other tests either you can do or need to refer the patient for.
Palpation Techniques
Findings Condition or Pathology
Implicated
Further Testing
Point of maximal Impulse
Left ventricular bulge
Left ventricular aneurism 1. Systolic blood pressure 2. Echocardiogram
Findings Condition or Pathology
Implicated
Further Testing
Point of maximal impulse
Lateral and downward
Cardiac dilation as in aortic regurgitations.
Right pneumothorax
1. Auscultation of right pleural space
2. Evaluation for Mediastinal Shift
Palpation Techniques Findings Condition or Pathology
Implicated
Further Testing
Hyperdynamic apical impulse or thrust
Increased tone of the myocardium as seen due to:
1. Mitral regurgitations 2. Aortic regurgitations 3. Exertional stress 4. Emotional stress 5. Thyrotoxicosis 6. Left ventricular hypertrophy
1. The patient's workload 2. The patient's mental stress level
3. Systolic blood pressure 4. Auscultation of the chest 5. Chest x-ray for enlarged heart
6. Thyroid level
Sustained and enlarged left ventricular impulse
Congestive heart failure 1. Heart rate
2. Systolic and diastolic blood pressure
3. Echocardiogram
Chest pain 1. Angina Ask the patient about the
Frequency
Intensity
Duration of chest pain
2. Trigger points Pain is greater in inspiration.
Palpate around the ribs and muscles that overlie them 3. Costochondral tenderness Pain is greater in inspiration.
Palpate the costal cartilages.
Deep midline pulsations
Finger span greater than 2 inches
Abdominal aortic aneurism Distal pulses of the legs
Palpation Techniques Findings Condition or Pathology
Implicated
Further Testing
Peripheral pulses Rate:
Less than 60 BPM in resting
Bradycardia EKG for dysrhythmias
Peripheral pulses Rate:
Greater than 100 BPM in resting
Tachycardia EKG for dysrhythmias
Peripheral pulses Rhythm
Irregular - irregular
Atrial fibrillation EKG for dysrhythmias
Peripheral pulses Rhythm
Regular - irregular (skipped beats)
Check EKG for
Premature ventricular contractions
Heart blocks
EKG for dysrhythmias
Peripheral pulses weak, thready
Hypotension Systolic and diastolic blood
pressure
Shin color and moisture (diaphoresis)
Peripheral pulses Asymmetric
Arterial occlusive disease Distal pulses
Distal skin color and temperature Capillary refill time Temperature and color
of skin hot and red
1. Thrombus Distal pulses
Distal skin color and temperature Capillary refill time
2. Inflammation Blood test for ESR and increased WBC count
3.Infection Core body temperature
Blood test for ESR and increased WBC count and blood culture
Palpation Techniques Findings Condition or Pathology
Implicated
Further Testing
Temperature of skin Cold and clammy
1. Hypotension Systolic and diastolic blood pressure
2. Arterial occlusive disease Distal pulses
Distal skin color and temperature Capillary refill time 3. Autonomic dysfunction Level of consciousness
Cranial nerve X Brain MRI, CT-scan
4. Raynaud's phenomenon For hand: test the upper quarter (neck and shoulder).
For foot: test the knee and hip
Observation of the Patient: is usually the first step when conducting an assessment. When looking for arterial circulation pay particular attention to the most distal areas like the fingers and toes.
Observation Technique
Findings Condition or Pathology
Implicated
Further Testing
Cyanosis of nail beds or lips Hypoxia Peripheral circulation tests Pulse oximetry
Systolic blood pressure
Clubbing of fingernails Tissue hypoxemia Peripheral circulation tests Pulse oximetry
Observation Technique
Findings Condition or Pathology
Implicated
Further Testing
Jugular venous distension Right side ventricular failure Systolic blood pressure
Cardiac apical pulsations 20% of the time this is normal, with children or very thin adults.
Patients with a lack of abdominal muscle tone.
80% of the time it is due to left ventricular failure
Test for abdominal muscle tone
Discolorations of the skin Peripheral atrial and venous disease.
White = a lack of perfusion.
Cyanosis = venous stasis
White: Distal pulses Cyanotic: Test for edema and deep vein thrombosis
Ulcerations, trophic changes of the skin
Peripheral vascular disease Diabetes mellitus
White: Distal pulses Cyanotic: Test for edema and deep vein thrombosis Peripheral edema
Bilateral
Congestive heart failure Assess blood tests for kidney, liver failure or protein levels
Peripheral edema Unilateral
Venous stasis Lymph edema
Test for edema and deep vein thrombosis
Blood pressure
Blood pressure is a measure of the force of blood inside an artery. If the pressure of blood is higher than normal, the person has high blood pressure (hypertension). The measurement is taken by momentarily stopping the flow of blood in an artery (usually by inflating a cuff around the upper arm) and then listening for the sound of the blood beginning to flow through the artery again as air is released from the cuff.
As blood flows through the artery, it can be heard through a stethoscope placed on the skin over the artery inside the elbow. Blood pressure is recorded as 2 measurements:
Systolic pressure. It is the reading on the gauge when blood flow is first heard. Systolic pressure represents the peak blood pressure that occurs when the heart contracts.
Diastolic pressure. This is the reading on the gauge when blood flow can no longer be heard. Diastolic pressure represents the lowest blood pressure that occurs when the heart relaxes between beats.
These 2 pressures are expressed in millimeters of mercury (mm Hg), because the original devices that measured blood pressure used a column of mercury. Systolic pressure, the higher of the 2 readings, is measured first. Diastolic pressure is the lower reading. These blood pressure measurements are recorded as systolic/diastolic. For example, if the systolic pressure is 120 mm Hg and the diastolic pressure is 80 mm Hg, your blood pressure is recorded as 120/80 and read as "120 over 80."
Korotkoff sounds are the sounds that medical personnel listen for when they are taking blood pressure using a non-invasive procedure.
KOROTKOFF SOUNDS
Phase 1 The first sound that you hear The first sound heard. The Systolic Reading. Clear tapping with increasing intensity
Phase 2 Clear tapping changes to a soft murmur
Phase 3 The sound changes to a crisp tapping
sound
Phase 4 The tapping changes to a soft blowing sound. First
Diastolic Reading
Phase 5 The last sound that you hear The sound disappears. The Second Diastolic Reading
Systolic blood pressure
Systolic pressure is the pressure of blood against the artery walls when the heart has just finished contracting or pumping out blood (reflecting the pumping force of the heart).
Systolic blood pressure is the upper number of a blood pressure reading. For example, if a person's systolic pressure is 120 millimeters of mercury (mm Hg) and the diastolic pressure is 80 mm Hg, blood pressure is recorded as 120/80 and read as "120 over 80."
Diastolic blood pressure
Diastolic pressure is the pressure of blood against the artery walls between heartbeats, when the heart is relaxed and filling with blood (reflecting the vasomotor tone), and the heart is relaxed and filling with blood. It is the second or lower number in a blood pressure reading.
The systolic pressure is generated by the left ventricle of the heart so this reading reflects the heart function. The pulse pressure is the systolic pressure minus the diastolic pressure. For example, if the diastolic pressure is 80 millimeters of mercury (mm Hg) and the systolic pressure is 120 mm Hg, the blood pressure is recorded as 120/80 and read as "120 over 80."
Hypertension
When systolic blood pressure levels are at or above 140 mm Hg, or when diastolic blood pressure levels are at or above 90 mm Hg, a person has high blood pressure (hypertension).
High blood pressure means that the heart must work harder to pump blood throughout the body.
Uncontrolled high blood pressure increases a person's risk of stroke, heart failure, kidney failure, and heart attack. As blood pressure increases, the risk of it causing these problems also
increases.
High blood pressure is often referred to as the "silent killer," because usually it has no obvious symptoms and most people cannot tell if their own blood pressure is high unless it is measured.
Normal Blood Pressures Newborn 40-70 systolic
2 Years 80-90 systolic, 55-65 diastolic 14 Years 120-140 systolic, 70-85 diastolic
Adult 110-140 systolic, 60-80 diastolic. Diastolic readings over 100 are dangerous and systolic readings over 170 at rest indicates caution should be taken with exercise.
Elderly 110-140 systolic, 60-80 diastolic, may be higher systolic and lower diastolic
Blood pressure monitors
The 2 general types of blood pressure monitors commonly available are manual and automatic.
(Automatic types may also be called electronic or digital).
Manual blood pressure monitors
This device is called a sphygmomanometer. These devices usually include an arm cuff, a squeeze bulb for inflation, a stethoscope or microphone, and a mechanical gauge or column of mercury to measure
the blood pressure. Manual blood pressure monitors require good eyesight and hearing for precise measurements. There are 2 basic styles of manual blood pressure devices.
Mercury column blood pressure devices. A column of mercury rises and falls in a clear tube with the units of measure marked along the side. As the cuff pressure increases, the mercury rises. As the cuff pressure falls, so does the mercury column. A stethoscope is required to listen for sounds of blood flow through the artery. Mercury column blood pressure cuffs are the most accurate of the blood pressure devices, but they are bulky, easily broken, and may be difficult to read. It takes practice to learn to use them properly.
Aneroid blood pressure devices. These display the blood pressure on a circular dial with a needle. As the pressure in the cuff rises, the needle moves clockwise on the dial. As the cuff pressure falls, the needle moves counterclockwise. Again a stethoscope is required; some models have the stethoscope head permanently attached to the cuff. The aneroid devices are compact and inexpensive but somewhat difficult to use. Also, the dial gauges may need to be recalibrated from time to time to maintain their accuracy.
Automatic (also called electronic or digital) blood pressure monitors
Electronic battery-operated monitors use a microphone to detect blood pulsing in the artery instead of having to listen with a stethoscope.
The cuff, which is attached to the wrist upper arm, is connected to an electronic monitor that automatically inflates and deflates the cuff when you press the start button.
First, place the wrist or upper arm inside the cuff. Then press the start button on the monitor and wait for a reading to display. The monitor records the pulse as well as your blood pressure.
The electronic devices are by far the easiest to use, but they are also very expensive. Generally, the electronic models that use an arm cuff are more accurate than those using wrist cuffs.
Methods of blood pressure measurement Auscultatory method:
After inflating the cuff and until the pressure is about 30 mm above the point where the radial pulse disappears, place the bell of the stethoscope over the brachial artery just below the blood pressure cuff.
Then, deflate the cuff slowly, about 2 to 3 mm Hg per heartbeat.
The first sound heard from the artery is recorded as the systolic pressure.
The point at which sounds are no longer heard is recorded as the diastolic pressure.
For convenience the blood pressure is recorded as figures separated by a slash. The systolic value is recorded first.
Note: Sounds heard over the brachial artery change in quality at some point prior to the point the sounds disappear. A few physical therapists consider this the diastolic pressure. This value should be noted when recording the blood pressure by placing it between the systolic pressure and the pressure noted when the sound disappears. Thus, 120/90/80 indicates a systolic pressure of 120 with a first diastolic sound change at a pressure of 90 and a final diastolic pressure of 80. The latter pressure is the point of disappearance of all sounds from the artery. When the values are so recorded, most physical therapists may use either of the last two figures as the diastolic pressure. When the change in sound and the disappearance of all sound coincide, the result should be written as follows: 120/80/80.
Palpation method:
The same arm, usually the right, should be used each time the pressure is measured.
The arm should be raised to heart level if the patient is sitting, or kept parallel to the body if the patient is recumbent.
The patient's arm should be relaxed and supported in a resting position.
Exertion during the examination could result in a higher blood pressure reading.
Either a mercury-gravity or aneroid-manometer type of blood pressure apparatus may be used.
The blood compression cuff should be the width and length appropriate for the size of the subject's arm: narrow (2.5 to 6 cm) for infants and children and wide (13 cm) for adults.
The inflatable bag encased in the cuff should be 20% wider than one third the circumference of the limb used.
The deflated cuff is placed evenly and snugly around the upper arm so that its lower edge is about 1 in. above the point of the brachial artery where the bell of the stethoscope will be applied.
While feeling the radial pulse, inflate the cuff until the pressure is about 30 mm above the point where the radial pulse was no longer felt.
Deflate the cuff slowly and record as accurately as possible the pressure at which the pulse returns to the radial artery.
Systolic blood pressure is determined by this method; diastolic blood pressure cannot be determined by this method.
This is used for taking a quick measure of blood pressure in a noisy environment.
Respiratory rate
The respiratory rate, more properly called the rate of ventilation, should be measured. Increasing the respiratory rate and depth is the fastest way to increase the oxygen levels to the tissues, but there is an increased energy expense. It is most efficient to increase the heart rate. This means that with most chronic conditions you will see an increased heart rate. If the heart rate/stroke volume increase alone cannot supply the tissues the ventilation rate is increased and in the extreme the depth of ventilation is increased. The simplest value is the respiratory rate.
Respiration Rates
Age Rate Warning
Premature infant 40-90bpm If below 30
Newborn 30–60 bpm If below 30
6-12 months 24-46 bpm
1 to 4 years 20-30 bpm
4-6 years 20-25 bpm
6 to 12 years 16-20 bpm
Adult 12-16 If under 10 and over 18 at rest and 20 during
exercise bpm = breaths per minute
Reference http://www.fpnotebook.com/Lung/Exam/RsprtryRt.htm
Note: infants and adult rates are on the NPTE. Infants tend to be in trouble when the rate is too low and adults when the rate is too fast.
The Relative Perceived Exertion (RPE) is a means of determining how hard the patient is exerting themselves, including both physiological (how hard they are breathing, how fast their heart is beating) and muscular (how much they feel the exertion in their muscles) strain.
The scale measures the answer to the question: "How hard do you feel the exercise is?"
Perceived Exertion (Borg Rating of Perceived Exertion Scale)
This scale may be the best way to monitor a patient that is taking a beta blocker as heart rate and systolic blood pressure is inaccurate.
For patients that cannot use their lower extremities an Upper Body Ergometer (UBE) is used. Upper body exercise is more stressful since it uses smaller muscle groups and tends to affect the
baroreceptors in the vena cava and the carotid sinus more. Patients doing upper body exercise tend to have a rapid increase in their vital signs.
Examinations:
Treatment procedures are always used in conjunction with examination techniques so that the therapist can monitor the safety and effectiveness of the treatment that is applied to the patient.
o Auscultation and percussion to evaluate the functioning of the lobes of the lungs.
o Auscultation to evaluate sputum movement.
o Pulmonary function testing to examine air movement.
o Blood tests pO2, pCO2 along with oxygen saturation to examine and monitor gas exchange.
Please review the tests and measures of the cardiopulmonary system and systems review of the cardiopulmonary system.
Identification of patterns of breathing:
Breathing Patterns
Affecting Pattern Description
Affecting Rate of Respiration
Apnea Absence of breathing
Eupnea Normal rate and rhythm
Orthopnea Only able to breathe comfortable in upright position (such as sitting in chair), unable to breath laying down.
Bradypnea Abnormally slow rate. In adults less than 12 respirations per minute. Seen with para sympathetic stimulation Tachypnea Abnormally rapid rate In adults greater than 30
respirations per minute. Seen with sympathetic stimulation
Shallow breathing Breathing in which the volume of inspired and expired air is diminished (e.g., <200 ml per breath in adults).
It is common in elderly patients, patients with rib or pleural pain, or obstructive lung diseases.
Sputum
Sputum shows a therapist what is going on in the airways and deep in the lungs. Sputum samples can be cultured and microscopically analyzed to determine the type of cells produced and infections that are present.
Pulmonary function testing Ventilation
Ventilation is measured by computing the volume of inspired air and the oxygen content (this is done through pulmonary function Spirogram) of that air and multiplying it by the number of ventilation per minute. This is called ventilation output.
Pulmonary ventilation
Pulmonary ventilation is commonly referred to as breathing.
It is the inspiration and expiration of air from the lungs or the movement of air into and out of the lungs.
In physiological terms, the amount of air inhaled per day.
This can be estimated by spirometry, multiplying the tidal air by the number of respirations per day.
An average figure is 10,000 L. Do not confuse this with the total amount of oxygen consumed, which is on the average only 360 L/day. These volumes are more than doubled during hard physical labor.
Alveolar ventilation
The movement of air into and out of the alveoli.
It is a function of the size of the tidal volume, the rate of ventilation, and the amount of dead space present in the respiratory system.
It is determined by subtracting the dead space volume from the tidal volume and multiplying the result by the respiratory rate.
Factors that Control Ventilation
Respiration is under the control of the autonomic nervous system. The factors, which can be both controlled and measured are the respiratory rate and the depth of ventilation
Pulmonary function tests:
On the NPTE a therapist needs to be able to conduct and interpret pulmonary function tests.
These tests are used to diagnose and objectively define pulmonary conditions. Conditions are usually split into two categories. The first being restrictive disease and the second being obstructive disease.
Spirometry
Spirometry measures how quickly your lungs can move air in and out. It can also measure how much air your lungs move in and out.
To conduct the test, the patient breathes into the mouthpiece of a long, flexible tube attached to a recording device called spirometer.
The information (volume of gas in relation to time), documented by the spirometer is printed out on a chart called a Spirogram.
The more common lung function values that may be measured include:
Tidal volume (VT). This uses a spirometer to measure the amount of air that is inhaled during a normal breath.
Vital capacity (VC). This uses a spirometer to measure the maximum amount of air the patient can exhale after they inhale as deeply as possible.
Forced expiratory volume (FEV). This uses a spirometer to measure the amount of air you can exhale forcefully in a sustained breath. The amount of air you exhale may be measured at 1 second (FEV1), 2 seconds (FEV2), or 3 seconds (FEV3).
Residual volume (RV). This uses gas dilution tests or body plethysmography to measure the amount of air that remains in your lungs after you have completely exhaled.
Total lung capacity (TLC). This uses gas dilution tests or body plethysmography to measure the maximum amount of air your lungs can hold when fully inflated.
Maximum voluntary ventilation (MVV). It is a measure of the maximum amount of air that can be inhaled and exhaled within one minute. This uses a spirometer.
Forced vital capacity (FVC). The total amount of air you exhale during this test is called the forced vital capacity (FVC). Forced expiratory volume is the most important
measurement of lung function. It is used to:
o Diagnose chronic obstructive pulmonary disease (COPD). A person with COPD has a lower FEV1 result than a healthy person.
o See how well medications used to improve breathing are working.
o Determine if lung disease is getting worse. Decreases in the FEV1 value may indicate the lung disease is getting worse.
Peak expiratory flow rate
Peak expiratory flow rate (PEFR) is a measure of how fast a person can breathe out (exhale) using his or her greatest effort. Peak expiratory flow may be measured at home using an inexpensive device called a peak flow meter, or it may be measured in the clinic using a spirometer as part of other lung function tests.
Peak flow rate is often used to evaluate a person who has asthma (or symptoms of asthma), which causes inflammation and narrowing of the tubes that carry air to the lungs (bronchial tubes). When the bronchial tubes get smaller, the peak flow rate drops. A decrease in the peak flow rate can show that the bronchial tubes have narrowed even before symptoms of asthma develop.
In a person who does not have asthma, the peak flow rate usually does not vary from its normal value by more than 10% at any time.
Diffusing capacity for carbon monoxide (DLCO). This is an estimate of your lungs' ability to transfer a gas (a very small amount of carbon monoxide) through the lining of the lung into the blood.
Radiographic tests
X-ray
X-rays are a form of radiation, like light or radio waves that can be focused into a beam, much like a flashlight beam. However, unlike other beams, X-rays can pass through most objects, including the human body.
When the X-rays strike a piece of photographic film, they produce a picture. The image produced is based on the various densities of the tissues:
Dense tissues such as those containing calcium (such as bone) block many of the rays and appear white.
Less dense tissues, such as muscles and organs, absorb fewer of the rays (more of the rays pass through) and appear as shades of gray. Areas of congestion passed by X-rays appear black. Structures containing air will be black, and muscle, fat, and fluid will appear as shades of gray.
CT (computerized axial tomography)
A CT (computed tomography) or CAT scan (computerized axial tomography) is a special type of X-ray that scans a specific area of the body one layer at a time.
A computer then analyzes the separate slices together and creates a 3-dimensional cross section of that part of the body.
A CT scan can detect problems that cannot be seen on regular X-rays, such as signs of infection, tumors, or abnormal changes in organs or glands.
Contrast material can be used in the same way as angiography to display arteries and veins.
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging is a type of diagnostic radiography that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body.
MRI scans are not possible for people who have certain types of implants fitted, such as a pacemaker (a battery-operated device that helps to control an irregular heartbeat).
MRI often provides more detail than other tests, such as a CT scan, and does not require X- rays or the injection of dyes or other substances.
It is often used to create images of the brain (where it can detect tumors, bleeding, aneurysm, or lesions from diseases such as multiple sclerosis)
Doctors use MRI to examine the brain, spine, joints (e.g., knee, shoulder, wrist, and ankle), abdomen, pelvic region, breast, blood vessels, heart and other body parts.
Observation of the Patient: is usually the first step when conducting an assessment. When looking for arterial circulation pay particular attention to the most distal areas like the fingers and toes. Look for skin color nail beds and trophic changes.
Electrocardiogram (EKG/ECG
Electrical Analysis of the Heart. It is not often available to the physical therapist except when seeing a patient for the purpose of cardiac rehabilitation or in an intensive care unit.
EKG/ECG Looks at the electrical conduction across the heart.
The Electrical conduction starts at the pacemaker, sinoatrial node (SA node), located in the lateral superior right atrium.
The depolarization flows through the atrium and down to the right inferior wall to stimulate the atrioventricular node (AV node) and across the left atria.
The AV node fires down the bundle of His to the right and left bundle branches in the Inter-ventricular septum and to the right and left ventricle firing them.
In the ventricles the wave of depolarization starts from the bundle branches that are located near the interior surface and progresses through the cardiac muscle from the inside to the outside. This allows for the relatively superficial location of the Purkinje fibers to contract just prior to the firing of the myocardium, thus closing the mitral and tricuspid valves prior to the walls of the ventricles contracting.
Repolarization of the ventricles follows in the reverse order of depolarization.
The base line The first thing that you may want to look at is the base line or isoelectric line this indicates the quality of the tracing as if there is electrical interference it will wander and may show 60 hz cycle interference (this mimics atrial fibrillation).
The most noticeable artifact on the ECG is the QRS complex starts at the Q wave by depolarization of the AV node and the amplitude is generated from the bundle of Hiss, the bundle branches and ventricular depolarization. This relates to ventricular function.
The amplitude of this wave relates to the hypertrophy of the ventricles. The duration if prolonged relates to a delay in conduction.
The waves
The wave before the QRS complex is the P wave which starts by the discharge of the SA node and is the electrical signal generated from the contraction of the atria.
The ST segment is generated from the repolarization of the ventricles. The J point is important in determining the slope of this segment. If the J point is above the isoelectric line it indicates myocardial damage, if it is below it indicates ischemia.
The U wave may indicate repolarization of the Purkinje fibers that close the valves. It is not normally observable with moderate to severe low potassium levels and digitalis toxicity.
The twelve lead EKG or ECG is used to view the electrical activity of the heart from different vectors.
Therapists need to be able to select the lead that is most appropriate to monitor the heart of a patient during testing and with exercise.
The therapist needs also be able to set up the leads on a patient. The most common are the limb leads I, II, III. To determine axis from the amplitude of waves in differing leads augmented leads are used, this gives insight as to the position of the cardiac muscle mass in relation to lead position. Precordial leads are also used to better view of specific portions of the heart. The arrangement of the leads produces the following anatomical relationships: leads II, III, and aVF view the inferior surface of the heart; leads V1 to V4 view the anterior surface; leads I, aVL, V5, and V6 view the lateral surface; and leads V1 and aVR look through the right atrium directly into the cavity of the left ventricle.
Important ECG changes and signs
Important ECG changes and signs
ST segment evaluation
The ST segment is very important to physical therapists. It directly relates to the heart muscle.
The concept of the J point comes out of cardiac rehabilitation and makes the electrocardiogram (EKG, ECG) easier to interpret and can also develop parameters for exercise.
Physiologically, during the ST segment K+ enters the myocardial cells as Na+ diffuses out. There needs to be a T wave for every depolarization (the QRS complex) to recharge the myocardium.
The ST segment is the flat, isoelectric section of the ECG between the end of the S wave (the J point) and the beginning of the T wave.
The ST segment is also affected by myocardial ischemia, necrotic myocardial tissue in a myocardial infarction (MI), and damaged myocardial tissue such as edema and
inflammation, and scar tissue from healed myocardium.
It represents the interval between ventricular depolarization and repolarization.
The most common cause of ST segment abnormality (elevation or depression) is myocardial ischemia/infarction.
The J point
One of the easiest ways to assess the ST segment is the use of the J point. The J point is located at the first deviation to the right after the S wave. Normally the J point should be at the ST segment should it occur at the isoelectric line. It can be below the isoelectric line, which is called a depressed ST segment or above the isoelectric line, which is called an elevated ST segment.
Depressed ST segment. This indicates myocardial ischemia and is usually associated with chest discomfort or pain which is called angina. The amount of ST segment depression is an indicator of cardiac stress.
Note: The slightly depressed J point in the above 12 lead EKG. This indicates that the heart is stressed. This can be from a workload from doing exercise or functional activities. During phase I cardiac rehabilitation ideally there should be no depression as it is not advisable to stress the damaged heart muscle. The maximal allowed depression should be no more than 1 mm. During phase III cardiac rehabilitation you want to stress the heart to strengthen it. A 2 mm. of ST segment is allowed.
ST segment elevation
This indicates subacute or chronic damage to the myocardial tissue. The myocardium heals through the process of autolysis followed by granulation like other muscles and the skin. Since the heart is beating as it is granulating, the collagen fibers are stretched which can lead to a hypertrophic, but weak myocardium as these collagen fibers do not contract.
As stated earlier, the most common cause of ST segment abnormality (elevation or depression) is myocardial ischemia/infarction.
Other causes are
Early repolarization
Acute pericarditis: ST elevation in all leads except aVR
Pulmonary embolism: ST elevation in V1 and aVR
Hypothermia: ST elevation in V3-V6, II, III and aVF
Hypertrophic cardiomyopathy: V3-V5 (sometimes V6)
High potassium (hyperkalemia): V1-V2 (V3)
During acute neurologic events: all leads, primarily V1-V6 by affecting the valgus nucleus and/or the thoracodorsal trunk
Acute sympatric stress: all leads, especially V1-V6
Brugada syndrome.
Cardiac aneurysm.
Cardiac contusion
Left ventricular hypertrophy
Idioventricular rhythm including paced rhythm
T wave changes
A concise list of possible causes of T wave changes:
Ischemia and myocardial infarction
Pericarditis
Myocarditis
Cardiac contusion
Acute neurologic events, such as a subarachnoid bleed.
Mitral valve prolapses
Digoxin effect
Right and left ventricular hypertrophy with strain Persistent myocardial ischemia
Subendocardial ischemia manifests as ST depression and is usually reversible. With this condition, the patient’s usual complain will be chest pain.
Electrolyte imbalances
Normally a greater concentration of sodium (Na+) diffuses into the muscle and nerve cells and potassium diffuses out of these cells to cause contraction of the myocardial fibers. In the heart potassium diffuse into the myocardial cells and sodium diffuses out of the myocardial cells to cause relaxation. Two factors are important in determining the effect that electrolytes have upon excitable body tissue. The amount of a type of ion that diffuses and the rate of diffusion.
The differential of the concentration of the electrolytes on either side of the membrane are one factor. The greater the concentration of one electrolyte the greater the force is created to drive the ions through the membrane. The faster the concentrations rise the greater the driving force and the less accommodation will occur.
Calcium causes the release of sodium, thus increasing the force of contraction. This can easily lead to overuse of the muscles and damage to the muscle tissue. This means active and resistive exercise may permanently injure the patient.
On an electrocardiogram:
The P and QRS represent depolarization
The T wave or the ST segment represents the repolarization or absolute refractory period.
Hyperkalemia
Hyperkalemia is defined as a serum potassium concentration greater than 3.5-5.5 mEq/L in adults; the range in infants and children is age-dependent 3.4-4.7 mEq/L or mmol/L.
Levels higher than 7 mEq/L can lead to significant hemodynamic and neurologic consequences, whereas levels exceeding 8.5 mEq/L can cause respiratory paralysis or cardiac arrest and can quickly be fatal. This increase in blood potassium level which causes a general decrease in depolarization amplitude and rate with a greater refractory period.
As a physical therapist:
o Vital signs you will notice is a decrease in the heart rate and blood pressure, both systolic and diastolic but the pulse pressure may be unchanged. The depth and frequency of ventilation may decrease. This can lead to shortness of breath and chest pain.
o Musculoskeletal system: Muscle weakness will occur. The greater the weakness with higher potassium levels. This can decrease patient function.
o Neuromuscular system: there is a decrease in nerve conduction velocity. This can result with memory dysfunction in terms of both short term and long term memory and paresthesia.
o Gastrointestinal system: problems can be nausea and vomiting.
From the medical record:
o Blood tests
Potassium level above 3.5-5.5 mEq/L in adults. Children: 3.4-4.7 mEq/L or mmol/L (age dependent).
Potassium levels greater than 7 mEq/L can lead to significant
hemodynamic (bradycardia and decreased blood pressure that can lead to coma) and neurologic consequences, confusion and the decreased muscular recruitment that causes weakness.
Potassium level exceeding 8.5 mEq/L can cause respiratory paralysis or cardiac arrest and can quickly be fatal
o Urine analysis
Adults: 25-125 mEq/L/day
Children: 10-60 mEq/L/day Differential diagnosis and causes:
o Renal failure or insufficiency and due to obstruction of the lower urinary tract o Acute Tubular Necrosis
o Congenital Adrenal Hyperplasia o Diabetes mellitus
o Metabolic Acidosis
o Sickle cell anemia or the sickle cell trait Dietary recommendations:
o Eating disorders (anorexia, bulimia)- Very unusual diets consisting almost exclusively of high-potassium foods, such as fruits (e.g., bananas, oranges, or melons), dried fruits, raisins, fruit juices, nuts, and vegetables with little to no sodium
o Heart-healthy diets - Very low–sodium and high-potassium diets recommended for patients with cardiac disease, hypertension, and diabetes mellitus
o Excessive potassium intake (dietary or intravenous)
o Use of potassium supplements in over-the-counter herbal supplements, sports drinks, dietary supplements such as noni (Morinda citrifolia) juice, salt
substitutes, or prescribed pharmacologic agents Medications:
o Potassium-sparing diuretics, which are especially popular in the treatment of cirrhosis and chronic heart failure
o Nonsteroidal anti-inflammatory drugs (NSAIDs) o Oral contraceptive agents, such as drospirenone o Digitalis Toxicity
o Angiotensin-converting enzyme (ACE) inhibitors o The combination of spironolactone and ACE inhibitors o Angiotensin-receptor blockers (ARBs)
o Direct renin inhibitors (e.g., aliskiren) o Cyclosporine or tacrolimus
o Antibiotics (e.g., pentamidine and trimethoprim-sulfamethoxazole) o Epsilon-aminocaproic acid (EACA)
Less common for PT
o Acute Tubular Necrosis
o Congenital Adrenal Hyperplasia
o Electrical Burn Injuries if high density electrical current flowed through a significant portion of the body for a significant amount of time.
o Head Trauma o Hypocalcemia
o Metabolic Acidosis (diabetes)
o Rhabdomyolysis from tissue injury such as multiple fractures, 3rd degree burns and crushing injuries
o Thermal Burns with significant Total Body Surface Area involved o Tumor Lysis Syndrome
o Infection, potassium chloride (K+Cl-) is part of the triple drug cocktail used in lethal injections for executions!
Pediatric patients:
o Potassium intake or recent blood product transfusion
o Risk factors for transcellular shift of potassium (acidosis) or tissue death or necrosis o Use of medication associated with hyperkalemia or accidental poisoning (by the child),
from medications for other family members, pets, or household visitors) o Presence or signs of renal insufficiency
Specific electrocardiogram findings:
Amplified R wave
P-waves are widened and of low amplitude due to slowing of conduction or decreased or disappearing P wave
QRS complex:
o QRS widening o fusion of QRS-T
o loss of the ST segment
Tall tented T waves
Hypokalemia
This condition occurs due to low potassium levels. There is a decrease in the ability to repolarize. Hypokalemia is defined as a condition in which the serum potassium level is less than 3.5 mEq/L (3.5 mmol/L)
Symptoms:
Gastrointestinal system: Constipation
Cardiopulmonary system: Feeling of skipped heart beats or palpitations
Neuromuscular system: Decreased ability to maintain concentration, anxiety, Fatigue, lack of endurance that leads to tingling or numbness as local neurotransmitters are depleted. Decreased cognitive abilities such as memory and judgement. Psychological symptoms (eg, psychosis, delirium, hallucinations, depression). Severe can lead to seizure
Musculoskeletal system: initial overuse of muscles. Muscle weakness or spasms in severe cases muscle damage
Endocrine system: decreasing blood sugar stability Signs:
Vital signs:
o Rate of ventilation and depth of ventilation usually normal unless severe which sees an elevation of the respiratory rate and
o Increased heart rate with irregularities. Fast and irregular pulse o Increased diastolic blood pressure
Observation:
o Fatigue, decreased or decreasing endurance
o Decreasing functional activity o Anxiety
o Abdominal pain
Blood tests and symptoms:
o If the urine potassium level is less than 20 mEq/L, consider the following:
Diarrhea and use of laxatives
Diet or total parenteral nutrition (TPN) contents
The use of insulin, excessive bicarbonate supplements, and episodic weakness
On the electrocardiogram: The ECG may show:
o Atrial or ventricular tachyarrhythmias,
o Decreased amplitude of the P wave, or appearance of a U wave.
o Decreased height of the P wave o Very wide QRS complex
o ST depression (myocardial ischemia) and flattening of the T wave o Negative T waves
o A U-wave may be visible on the electrocardiogram
Differential diagnoses:
Hyperthyroidism
Hyperglycemia: Ketoalaklosis, low blood sugar, insulin shock
Cushing’s syndrome
Hypercalcemia
Hypercalcemia can result when too much calcium enters the extracellular fluid or when there is insufficient calcium excretion from the kidneys. Approximately 90% of cases of hypercalcemia are caused by malignancy or hyperparathyroidism.
Symptoms:
Neuromuscular system: Lethargy, confusion, coma
Musculoskeletal system: Weakness, due to overuse
Cardiopulmonary system: Syncope from cardiac arrhythmias
Urinary system: Polyuria, Nocturia (excessive urination during the night), dehydration, renal stones, renal failure
Gastrointestinal system: Constipation, nausea, anorexia, pancreatitis, gastric ulcer Tests and measures:
Vital signs: Increased resting heart rate with an irregular rhythm, increased diastolic blood pressure
Blood tests:
o Mild: Total Ca 10.5-11.9 mg/dL (2.5-3 mmol/L) or Ionized Ca 5.6-8 mg/dL (1.4-2 mmol/L)
o Moderate: Total Ca 12-13.9 mg/dL (3-3.5 mmol/L) or Ionized Ca 8-10 mg/dL (2- 2.5 mmol/L)
o Hypercalcemic crisis: Total Ca 14-16 mg/dL (3.5-4 mmol/L) or Ionized Ca 10-12 mg/dL (2.5-3 mmol/L)
Effect on delivery of physical therapy treatment:
Mild hypercalcemia – passive and low intensity activity interventions should be used.
Moderate hypercalcemia – passive treatments only, refer the patient to a physician
Hypercalcemic crisis (severe) – hold all activity, activate the emergency medical system Causes:
Hypercalcemia from malignancy usually is rapidly progressive; thus, rapidly rising calcium levels should increase suspicion of malignancy.
Hypercalcemia from hyperparathyroidism is usually mild, asymptomatic, and sustained for years. The therapist should look in the medical record for: Immunoreactivity of the parathyroid hormone (PTH) and ionized calcium should be simultaneously measured The electrocardiogram shows:
o Mild: broad based tall peaking T waves o Severe:
Extremely wide QRS
low R wave
Disappearance of p waves
Tall peaking T waves.
Hypocalcemia
The electrocardiogram shows:
o Narrowing of the QRS complex o Reduced PR interval
o T wave flattening and inversion
o Prolongation of the QT-interval (wide QRS) o Prominent U-wave
o Prolonged ST and ST-depression
Ectopic Complexes
Normal conduction in the heart starts at the sinoatrial node and depolarizes the atria first. This wave of depolarization triggers the atrioventricular node that is located in the septum between the atria and the ventricles and between the right and left sides of the heart. This continues down the bundle of his dividing into the right and left bundle branches. The tissue that carries this electrical conduction is not nerve but myocardial fibers that are more irritable.
Depolarization starting from the sinoatrial node normally produces a heart rate of 80-120 beats per minute. Deprivations starting from the atrioventricular node normally produce a heart rate of 40-60 beats per minute. These are called junctional rhythms.
Ectopic beats (foci) start from different areas of the myocardium. Since they are coming from an abnormal area of the myocardium their shape is different from normal waves.
There are atrial ectopic foci that may decrease the pumping action of the heart only a minimal amount, thus are insignificant as far as altering the physical treatment plan or delivering of physical therapy treatments to patients.
On an electrocardiogram you see abnormal P waves. There are ventricular ectopic beats as well. These produce different types of QRS complexes. The significance of these are more in their frequency; 4 or more per minute therapy should not be started, 6 or more during therapy exercise or activity should be stopped and if there is a relationship between the number of ectopic foci and the stress level, therapy should be stopped and the patient should be referred back to the physician. However, if they are repeated, causing an abnormal rhythm such as bigeminy or trigemini, the therapist should hold therapy.
Ectopic foci are from hyperirritable tissue; this can be due to electrolyte imbalance (too much sodium) or ischemia.
Heart cells with pacemaker activity
Cell type Frequency QRS width (*) Heart rate
SA node (not ectopic)Normal 60-100
bpm narrow Normal/tachycardia if
above 120 bpm at rest
Atrial 55-60 bpm narrow
Bradycardia in adults that are non-athletes AV Nodal ectopic pacemaker 45-50 bpm narrow
His bundle 40-45 bpm narrow
Bundle branch 40-45 bpm narrow or wide
Purkinje cells (these contract to
close valves) 35-40 bpm wide
Myocardial cells 30-35 bpm wide
Most often after an ectopic beat there is a longer refractory period (compensatory) so you see a flat line for a longer duration until there is another depolarization. If you are taking the pulse for rhythm you feel an irregular pulse at an irregular rhythm.
This is a premature atrial contraction (PAC) with an extended refractory period after the second pulse.
This is a premature ventricular contraction (PVC) in the third complex, again note the slightly extended refractory period.
Differential diagnosis of arrhythmias
Atrial arrhythmias13
These are abnormal electrical conduction across the atria. The physical therapist should note and report these abnormalities, but since they may decrease the heart performance only slightly they have little effect on the physical therapy treatment plan or delivery of physical therapy.
Sinus arrhythmias
Some variants of sinus rhythm exist:
Asystole. During asystole there is no cardiac activity. When prolonged this results in immediate death. Again, asystole is a very unlikely diagnosis in a conscious patient and a
technical error should be checked first (loose wire, very low gain). Although often called a 'flatliner', the baseline in asystole is often shifting up and down a little and in fact if it isn't (and looks like as it is often depicted in movies) a loose wire is the most likely cause.
Sinus tachycardia (>100 beats per minute)
Sinus tachycardia is sinus rhythm with a rate of > 100bpm. Sinus tachycardia is an example of a supraventricular rhythm. In sinus tachycardia the sinus node fires between 100 and 180 beats per minute, faster than normal. The maximal heart rate decreases with age from around 200 bpm to 140 bpm. The maximal heart rate can be estimated by subtracting the age in years from 210. Sinus tachycardia normally has a gradual start and ending. Most often sinus tachycardia is caused by an increase in the body's demand for oxygen, such as during exercise, stress, infection, blood loss and hyperthyroidism. It can also express an effort of the heart to compensate for a reduced stroke volume, as seen during cardiomyopathy.
o The maximal heart rate is considered to be 220/min minus the age (or more precisely 207-0.7xAge. However, this is often exceeded during vigorous exercise and has a large inter-individual variation.
o Appropriate sinus tachycardia can result from:
Exercise
Anxiety
Alcohol/caffeine use
Drugs (e.g. beta-agonists like Dobutamine) This is used for s drug induced cardiac stress during a stress test
o Inappropriate sinus tachycardia can result from:
Fever
Hypotension
Hypoxia
Congestive heart failure
Bleeding
Anemia
Hyperthyroidism
Cardiomyopathy (with reduced left ventricular function and compensatory tachycardia)
Myocarditis
o Inappropriate sinus tachycardia is rare and characterized by tachycardia at rest and exaggerated acceleration of the heart during physiologic stress. The mechanism leading to an exaggerated response of the sinus node to minimal physiologic stress is not completely understood.
Types of Arrhythmias
Atrial Fibrillation13
During atrial fibrillation the atria show chaotic depolarization with multiple foci. Mechanically the atria stop contracting after several days to weeks of atrial fibrillation, the result of the ultra- rapid depolarizations that occur in the atria are typically around 400 bpm, but up to 600 bpm.
At the AV node 'every now and then' a beat is conducted to the ventricles, resulting in an irregular ventricular rate, which is the typical ECG characteristic of atrial fibrillation. Sometimes atrial fibrillation results in a course atrial flutter wave on the ECG, but the baseline can also be flat. A flat baseline is more often seen in long standing atrial fibrillation. The cardiac stroke volume is reduced by 10-20% during atrial fibrillation, as the 'atrial kick' is missing and because the heart does not have time to fill at the often higher ventricular rate. Causes age (+- 10% of 70+ year olds and 15% of 90+ year olds have AFIB), ischemia, hyperthyroidism, alcohol abuse.
Atrial fibrillation can be categorized as follows:
First documented episode
Recurrent atrial fibrillation: after two or more episodes.
Paroxysmal atrial fibrillation: if recurrent atrial fibrillation spontaneously converts to sinus rhythm.
Persisting atrial fibrillation: if an episode of atrial fibrillation persists for more than 7 days.
