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  • Print publication year: 2015
  • Online publication date: July 2015

3 - Circulation

from Section 1 - Ward care (level 0–2)

Summary

Assessment

Cardiac assessment

Which basic investigations may be used in assessing cardiovascular function?

Following basic clinical examination of the praecordium during a cardiovascular examination, investigations may include

Non-invasive

Pulse: this is a clinical assessment of rate and rhythm, e.g. radial artery, and volume and character, e.g. carotid artery

Non-invasive blood pressure (NIBP): this employs a sphygmomanometer, e.g.manual measurement, or a Dinamap®, e.g. automated monitoring.The Dinamap® can measure absolute values, mean and pulse pressure, but mercury measurement is more accurate

Electrocardiograph (ECG):measures the rate, rhythm, intervals, axis and waveforms

Transthoracic echocardiography (TTE):measures systolic function, cardiac filling, valve function general morphology and

blood flow

Radiology: plain chest radiography (cardiothoracic ratio), CT, MRI

Other non-invasive assessments include the clinical evaluation of GCS, as a marker of cerebral perfusion, capillary refill time and urine output as markers of cardiac index (CI) and organ function, e.g. renal function.

Invasive

Intra-arterial blood pressure (IABP): e.g. radial arterial line, exhibits a continuous arterial waveform and beat to beat variation

Central venous catheter (CVC): e.g. internal jugular vein, measures the central venous pressure (CVP) or its response to fluid challenges and inotropes.The waveform may be continuously displayed

Pulmonary artery flotation catheter (PAFC): provides both direct and derived measures of left heart function, e.g. cardiac output. It also measures systemic and pulmonary vascular resistance, e.g. pulmonary artery capillary wedge pressure (PACWP), oxygen delivery, SaO2 and demand

Transoesophageal echocardiography (TOE [TEE]): Gives a more detailed picture of the left heart and thoracic aorta than transthoracic echocardiography

Cardiac catheterisation and coronary angiography: is the gold standard diagnostic procedure regarding the structure and function of the heart

Other invasive assessments of cardiac index and peripheral organ perfusion include

Arterial blood gases (ABGs): to assess the acidosis and base excess associated with anaerobicmetabolism following poor tissue perfusion

Biochemistry: rising serum lactate levels indicate a poor cardiac index

Gastric tonometry: adequacy of splanchnic perfusion is estimated fromgastric intramucosal pH measurements using a gastric probe.The gut is the first organ system to reflect a poor peripheral perfusion

Arteriovenous oxygen difference (a–vO2): oxygen extraction is increased in cases of poor organ perfusion due to relative stagnation

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