1 Flashcards
(247 cards)
1
Q
artery that supplies heart conducting system
A
RCA
2
Q
How purkinje fibers depolarize ventricles
A
base to apex
3
Q
RCA supplies what
A
RA/RV, part of inferior wall LV
4
Q
right dominant circulatory means what
A
RCA gives rises to PDA. 85%
5
Q
PDA supplies what in heart
A
posterior-superior interventricular septum and inferior wall of LV
6
Q
LMCA supplies what
A
LA, most of inter ventricular septum, LV(septal, anterior and lateral walls)
7
Q
what supplies bundle of his
A
PDA and LAD
8
Q
CO to heart
A
5%, 250mL/min
9
Q
extraction ratio of heart
A
65%
10
Q
EKG inferior MI
A
II, III, aVF
11
Q
EKG lateral MI
A
I, aVL, V5-V6
12
Q
EKG anterior MI
A
V3-4
13
Q
EKG septal MI
A
V1-2
14
Q
EKG lead most sensitive for ischemia
A
5, 75% sensitivity to detect ischemia
15
Q
TEE view to detect ischemia
A
trans gastric short-axis because you can visualize all 3 major coronary territories
16
Q
valve w/ 2 flaps
A
mitral
17
Q
normal area aortic valve
A
2.5-4.5cm2
18
Q
mitral valve normal area
A
4-6cm2
19
Q
sympathetic innervation to heart
A
cardioaccelerators T1-4 travel via stellate ganglion
20
Q
parasympathetic input to heart
A
from nucleus ambiguous in medulla
21
Q
sidedness of heart ANS
A
R to SA node. L to SV node
22
Q
transplanted heart connections
A
no parasympathetic(vagus), no cardioaccelerator T1-4 and no baroreceptor reflexes. dependent on SV to change CO
23
Q
what transplanted heart responds to for bp
A
isoproterenol, epi, dopamine and dobutamine aka sympathomimetic amines
24
Q
myocyte AP
A
Na voltage gated channel open going in cell. then K open out of cell then Ca open influx
25
actions potential length in myocyte
200msec
26
pacemaker cell action potential channel
Ca first not Na
27
intrinsic rate of SA, AV and purkinje
SA 70-80, AV 40-60 and P 15-40
28
lusitropy
rate of relaxation after cardiac contractile. dependent on phospholamban which inhibits reuptake of Ca into sarcoplasmic reticulum
29
heart rate regulation in brain
medulla
30
ANS receptor in heart
b1-2 sympathetic. M2 parasympathetic
31
percent atrial kick adds
20-30% of ventricular filling
32
atrial pressure wave a
end of Atrial contraction
33
atrial pressure wave c
rv Contraction, triCuspid bulge
34
atrial pressure x
atrial relaXation
35
atrial pressure v
Venous filling
36
atrial pressure y
rapid emptYing of atrium
37
a fib on atrial pressure wave
loss of a wave and prominent c wave
38
AV dissociation on pressure wave
cannon a wave
39
tricuspid regurg on atrial pressure wave
tall c-v wave. no x descent
40
RV ischemia on atrial pressure wave
tall a and v waves. steep x and y descents
41
cardiac tamponade on atrial pressure wave
dominant x decent and attenuated y descent
42
s1 and s2
s1 close AV. s2 close Aortic and pulmonic
43
s3
reverberation of blood rapidly filling ventricle(benign in youth, athlete or preggo)
44
S4
blood filling stiff ventricle
45
normal SVR
900-1500
46
normal PVR
50-150
47
which chamber of the heart is more sensitive to dysfunction in increased afterload
RV
48
E/A ratio
early diastole filling to atrial kick phase measured on doppler
49
E/A ratio normal
.8-1.2, low= impaired relaxation.
50
when E/A isn't predictive of diastolic fxn
heart valve problems or operator error
51
primary determinant of myocardial oxygen demand
heart rate
52
ohm's law
change in pressure = force x resistance
53
parasympathetic receptor on arteries
m3
54
Reynold's number
over 2000 means turbulent flow
55
blood volume in venous circulation
64%
56
carotid baroreceptor nerve
IX glossopharyngeal nerve called hearing's nerve
57
aortic baroreceptor nerve
vagus
58
bainbridge reflex
increased right atrial pressure from more blood back so then tachycardia. common after baby delivery
59
behold jarisch reflex
hypotension, bradycardia and coronary artery dilation in response to sympathetic overactivity causing contraction of an underfilled ventricle
60
Cushing reflex
elevated ICP- hypertension, bradycardia and abnormal breathing
61
coronary blood flow ewquation
(art dp-LVEDP)/coronary resistance
62
normal blood flow to brain
50cc/100gm /min
63
what can be used to prevent SVT in WPW
droperidol. WPW is pre-excitation abnormality. contraindicated verapamil and digoxin because they suppress normal conduction and enhance abnormal. drop- suppresses antero and retrograde conduction to stabilize HR
64
digoxin moa
blocks Na/K pump so up Ca(contractility), decreases AV node conduction(b/c down K). give for CHF, a-fib.flutt,
65
digoxin toxicity
tachydysrhythmias, decreased nodal conduction leads to Brady and AV block. potentiated by abnormal K(diuretic). can see hockey stick EKG
66
treatment of digoxin toxicity
lidocaine to increase AV conductance, phenytoin, amio, K,
67
adenosine moa
suppress AV nodal conduction used to treat WPW and other supra ventricular tachycardia(narrow complex). antagonized by caffeine, amio and theophylline
68
classes of antiarrhythmics
I: Na channel blocker. 2 b blockers. 3 K channel blockers and 4 Ca blockers
69
class IV anti-arrhythmics
Ca blockers verapamil and diltiazem
70
amiodarone
depresses SA/AV nodal conduction. SE: hypotension, Brady, heart block, depression of contractility, thyrotoxicosis, pulm fibrosis, up LFT, blue skin
71
QT prolonging meds
antiarrhythmics, antipsychotics(haloperidol/reiperidone), anti fungal(ketoconazole, fluconazole), abx(bacterium, erythromycin), antidepressants(TCA), GI(zofran)
72
alpha 1 receptor
vasoconstriction of bv, smooth muscles and gluconeogenesis. Gq protein
73
alpha 2 receptor
feedback mechanism inhibits insulin release, stimulates glucagon release, inhibits NE release. Gi protein
74
b1 receptor
up chronotropy, dromotropy(impulse conduction), up EF. Gs protein
75
b2 receptor
smooth muscle relaxation of bronchus, uterus, inhibits glucose release, stimulate gluconeogenesis, lipolysis, Gs protein
76
med to avoid in MAOI
ephedrine because indirect sympathetic and can cause exaggerated effect in MAOI
77
dobutamine
.b1, b2 to up CO good for cariogenic and septic shock. avoid in hypotension, arrhythmogenic and can cause tachyphylaxis
78
dopamine low dopamine agonist, high a1, a2, b1
up CO and mild increase SVR good for neuro, septic and cardiogenic shock
79
Epi
a1-2, b1-2. up HR, SVR and CO. for hypotension, bronchospasm, anaphylaxis(stabilize mast cells directly), can cause hyperglycemia
80
NE
a1, b1, b2 agonist. vasoconstriction
81
phenylephrine
a1 agonist to up SVR good for sepsis
82
vasopressin
V1, V2 agonist. vasoconstriction and water reabsorption for sepic shock. good in setting of acidosis. can cause lactic acidosis, abdominal cramp, bronchoconstriction
83
isoproterenol
synthetic catecholamine to b1-2. up HR, CO, contractility, down after load and PVR
84
milrinone
inhibit PDE so up cAMP. leads to ionotropy, lucitropy, dromotropy, chronotropy. up HR, CO. down SVR and PVR
85
nitroglycerine
direct vasodilator(v over a).
86
nitroprusside
decomposes to NO to relax smooth muscle. forms cyanide. give thiosulfate to tx
87
hydralazine
activates K channels on vascular smooth. muscle to cause depolarization/relaxation. causes tachycardia. good for preggo. can cause lupus like syndrome or agranulocytosis
88
ca blockers
down bp. verapamil/dilt also treat tachyarrhythmias. nifedipine only smoother muscle dilation
89
what not to give with verapamil
b blocker. too much hypotension
90
ace and arb words
ace- pril. arb (sartan)
91
hypercalcemia signs
groans, moans, bones, stones, and psychic undertones. short qt and bradycardia.
92
which prostaglandin increases GFR
E2. also ANP, dopamine
93
major function of proximal tubule
Na resorption and water follows.
94
what molecules enhance Na reabsorption in the pro tubule
angiotensin II and NE
95
what activates D1 receptor
dopamine and fenoldopam which decrease prop reabsorption of Na in kidney
96
what percent does proximal tubule reabsorb
75
97
amount of bicarb reabsorbed in kidney
90
98
cell types in collecting duct
principal cells that secrete K and participate in aldosterone-mediated Na reabsorption
Intercalated cells which help w/ acid/base regulation
99
site of ADH action
medullary collecting duct. V2 receptor activation causes open of aquaporin to reabsorb water
100
where is renin
juxtaglomerular apparatus
101
renin story
renin released to blood and turns angiotensinogen (liver) to angiotensin I. Lung's ACE makes angiotensin II. it acts in prox tubule to up sodium reabsorption
102
CO of kidney
25%
103
part of kidney vulnerable to ischemia
medulla
104
GFR percent of renal. plasma flow
20%
105
what is a good measure of GFR
inulin because completely filtered but not secreted or absorbed
106
normal GFR
120 men, 100 cc/min women
107
creatinine clearance and GFR comparision
creatinine clearance over estimates GFR because it is also secreted
108
when does GFR stop
under 40 MAP
109
adenosine on kidney
local release causes dilation of afferent arteriole and inhibits renin release
110
ANP on kidney
dilate afferent, maybe constrict efferent so up GFR. inhibits renin and aldosterone too
111
plamsa osmolality equation
2Na + BUN/2.8 + glucagon/18
112
osmol gap cause
ethanol, mannitol, methanol, ethylene glycol, isopropyl alcohol, glycine(TURP),
113
fluid compartments
intracellular 2/3 of TBW. extracellular 1/3---75% interstitial and 25% intravascular
114
diuretic that causes hyper K
thiazide
115
osmotic diuretic example and other effects
mannitol. it's also a free radical scavenger, can cause pulm edema
116
loop diuretic MOA and SE
inhibit Na and Cl reabsorption in thick ascending loop. reversible hearing loss
117
where thiazides work and SE
inhibit Na reabsorption in distal tubule. hypoK. metabolic alkalosis, hyperglycemia
118
where K sparing diuretics work, example and SE
collecting tubules. spironolactone(aldosterone receptor blocker). High K and metabolic acidosis, gynecomastia
119
fenoldopam
selective Dopamine 1 receptor agonist. decreases PVR, up renal blood flow and diuresis. good for cardiac/aaa repair because of antihypertensive and renal sparing properties
120
extraction ratio equation
intrinsic hepatic clearance / hepatic blood flow
121
flow dependent drug elimination characteristics
high extraction ratio, most eliminated first pass, rapid metabolism
122
capacity limited drug elimination characteristics
dose dependent, zero order, hepatic elimination determined by plasma concentration, when dosing exceeds liver capacity, plasma level rises
123
drugs with poor extraction ratio from liver
acetaminophen, asa, clinda, diazepam, digoxin, ethanol, phenytoin, warfarin
124
cup inducers
anesthetics, anticonvulsants, insecticide, sedative, steroid, HAART, st John wort
125
crossmatch
45min. donor and recipient blood. 1-rechecks ABO/lewis. 2-at 37C in albumin checks Rh
126
most labile coagulation factor
7
127
indications for FFP
correction of factor deficiency when don't have recombinant. PT/PTT over 1.5x normal. correction of microvascular bleeding during massive transfusion, urgent reversal of warfarin
128
how long do platelets last
5 days
129
indications for platelets
under 50 with ongoing bleeding or DIC or needs invasive procedure. if drops under 10
130
platelet change for 1u whole blood, 1 u apheresis,
10k, 30-50k
131
blood product most likely to spread virus
platelets. short life so can't test for nucleic acids
132
blood product you don't need ABO compatibility on
platelets. desirable but not absolutely required. need Rh though for female childbearing age. also cryo
133
what blood product not to give through warmer
platelets
134
cryo indications
fibrinogen under 100, ppx for hemophilia A, vWD, congenital dysfibrinogenemias, bleeding due to uremia not responsive to DDAVP
135
factors in cryo
8, 13, vWF, fibrinogen
136
who gets anaphylaxis to blood products
IgA deficient patients. reacting to donor IgA.
137
mild allergic run blood most common
ffp
138
febrile ran blood
pt antibody against donor wbc. 1 degree up in 4 hours
139
when does trali occur and tx
6 hours after transfusion. non cariogenic pulmonary edema, fever/chill, b/l infiltrates on CXR. mechanical ventilation, strict fluids, pulm hygiene, nebulizer
140
least common cause of TRALI
pRBC (least amount of plasma in it)
141
coagulopathy of blood transfusion
1.5x blood volumes, fibrinogen decreases. 2x Factor 2,5 8 down. 2.5 x then platelets decrease
142
stored pRBC pH
7.0 secondary to lactate and CO2 accumulation
143
4 platelet steps
adhesion via vWF/GP1B. 20 shape change/mediator release(thromboxane, prostaglandin, histamine. 2- aggregation Gp2B-3A. emergence of PF3 on platelet where coagulation cascade starts
144
abciximab moa
GP2B3A inhibitor so no platelet aggregation
145
point of coagulation cascade
make thrombin which turns fibrinogen to fibrin
146
what protein. and S do
degrade factor 5 and 8
147
factor 13 job
cross link fibrin together
148
tap moa
degrades fibrin
149
txa job. aminocaproic acid
promote fibrinogenesis. stabilize clot
150
factors tested in INR
extrinsic. 1, 2, 5, 7, 10
151
aPTT normal but long PT means what
factor 7 because shortest half life
152
PTT tests what factors
1, 2, 5, 8, 9, 10, 11, 12 (not 7 and 13)
153
normal ACT
90-120 sec
154
"poor man's PTT"
ACT
155
give heparin and act doesn't prolong then what
antithrombin 3 deficiency so give FFP
156
decreased amplitude on TEG
decreased platelet activity
157
end slope of TEG
give TPA if goes down fast. too much fibrinolysis
158
asa moa
irreversible plt cox inhibitor which prevents txa2 a potent plt pro-coagulant
159
cox2 inhibitor
celecoxib to mediate pain/inlammation while not causing gastric damage, decreased renal blood flow and inhibit plt txa2
160
calcium level for tetany/arrhythmia
less than o.5
161
high calcium sign
over 1.7 is coma. otherwise stones, bones, grones and psychic over tones
162
secreted from adrenal medulla
80% epi, 20% ne and little dopamine
163
nicotinic vs muscarinic
N: ion channel. receptor is everywhere
M: G protein membrane protein. in parasympathetic system so used to counteract nicotinic side effects of reversal
164
pressure needed for jet ventilation
15psi
165
highest pH IVF
albumin at 7.4 and plasmalyte
166
T1/2 of NS
30min
167
lithium and anesthesia
d/c b/c prolongs NMBA
168
valproate and anesthesia
interferes with platelet function
169
carbamazepine and anesthesia
induces p450
170
why procaine is bad for spinal
short(less than hour), more nausea, high anesthetic failure rate, slower recovery time PACU, but better because less back/leg pain than iidocaine
171
spinal w/ lido length
1.5 hours
172
adhesive arachnoiditis cause
chlorprocaine but because of the preservative so since changed and ok.
173
ropivicaine vs bupivicaine
ropi is half as potent but safer cardiac but less motor block
174
why neuraxial neostigmine is bad
nausea
175
2 MOA that occur when anticholinesterases are given neuraxial
inhibits acetylcholinesterase so more ach around to mitigate nociception. also increase concentration of NO. which is good in spinothalamic tract
176
specific gravity of CSF
1.0069
177
what influences peak block height of a spinal
patient height, site of injection, csf volume, baricity of med, dose of med, posture of patient
178
2 chloroprocaine onset and duration epidural w/ epi
10-15min and lasts 60-90min
179
lido onset and duration epidural w/ epi
15min, lasts 120-180min
180
bupivacaine onset and duration epidural w epi
20min and 3-4hours
181
ropivacaine onset and duration epidural w/ epi
15-20min and 2-3 hours
182
sodium bicarb on epidural
1mEq addition to 10 mL 1.5% lido makes significantly faster onset and better spread
183
sympathectomy level w/ neuraxial
epidural same level. spinal 2 levels above sensory
184
volume for blood patch
20cc
185
why isn't chlorpromazine used for iV anessthesia
causes phlebitis
186
local that causes mehemoglobinemia
prilocaine
187
how long does the turniquet have to be up for bier
at least 25min
188
protein binding molecules in plasma
albumin binds acidic drugs. alpha-1 glycoprotein binds basic drugs
189
meds that can have tachyphylaxis
ephedrine, opioids, nitroglycerine, ddavp, hydralazine, reglan, ranitidine, local anesthetics
190
risk factors for ulnar neuropathy
head rotation away, excess arm abduction, arm pronation, male, extremes of body habitus
191
saphenous nerve compression surgery location
medial tibial condyle from leg holder
192
femoral nerve injury surgery
kinked under inguinal ligament from extreme flexion and abduction of thighs
193
foot drop nerve
common peroneal
194
when to draw tryptase
within 5 hours after anaphylaxis
195
sublingual to core temp
sublingual 0.5C under
196
meperidine metabolism
to normeperidine in liver. can cause myoclonus and seizures
197
morphine metabolism
in liver to m6glucoronide(more potent than morphine) and m3g(inactive)
198
hydromorphone metabolism
to hydromorphone3glucuronide may cause cognitive dysfunction and myoclonus
199
where to epidural opioids exert their effect
substantia gelatinosa in dorsal horn
200
volatiles on icp and cmro2 and cbf
all up cbf and icp. nitrous oxide up cmro2, others down
201
nitrous toxicity things
megaloblastic hematopoiesis from marrow failure, subacute combined degeneration of spinal cord(numb/falls/weak), immunosuppression(impaired chemotaxis), teratogenic(skeletal and limb, situs inverus),..prolonged exposure
202
ppm numbers
nitrous 25, volatiles are 2
203
most IV anesthetic targets
gaba potentiation except ketamine...NMDA block
204
when to avoid barbiturates
hemorrhagic shock because significant myocardial depressant
205
ALA synthetase
induced by barbiturates so causes acute porphyria attack
206
intra artery inject of what is bad and how to treat
barbiturates. treat with papaverine/lidocaine, heparizination and consider regional techniques for pain
207
long acting benzo
diazepam
208
intermediate acting benco
lorazepam
209
when prolonged propofol infusion
over 4mg.kg.hr for 48 hours. metabolic acidosis, fatty liver, rhabdo, mitochondrial dysfunction, refractive bradycardia
210
common SE etomidate
pain at injection site/thrombophlebitis and a lot of n/v
211
phobicity of fentanyl vs morphine and why it matters spinal
f lipophilic. m hydrophilic. hydro slower onset, stays in csf longer so spreads higher and lasts longer
212
opioid receptor euphoria
m1
213
m2 opioid receptor job
hypoventilation, constipation, dependence
214
opioids histamine
morphine and meperidine most
215
mu receptor where spinal
substantia gelatinosa which inhibits release of substance P
216
methadone moa and loa
mu agonist and nmda antagonist. T1/2 15-60hours, variable due to cup variation
217
meperidine difference
atropine like structure so can have vagolytic effects. good for shivering. can cause serotonin syndrome
218
serotonin syndrome effects
headache, agitation, hallucination, coma, shiver, sweat, up T, tachycardia, nausea, myocolus, tremor
219
more allergenic locals
esters
220
locals with the "I"
amides
221
onset local based on what
pKa. lower means higher fraction of neutral drug so faster onset. only de protonated can cross
222
potency of local based on what
hydrophobicity. which improves transit across membrane
223
duration of locals based on what
protein binding
224
procaine different
methemoglobinemia, less likely TNS, high n/v
225
benzocaine different
paba allergic, methemoglobinemia
226
chlorprocaine different
quick onset, arachnoiditis from EDTA, decreased clearance in hepatic/renal dysfunction
227
tetracaine different
longer duration of action and motor, TNS risk
228
percent occupied if TOF
up to 70% still
229
nerve stimulator orbicularis occult vs adductor pollicis
eye mimics laryngeal mm. adductor pollicis comes back after laryngeal
230
o2. cylinder
700L gas at 2200psi
231
n2o cylinder
1600 L max pressure 750 psi
232
type of system mapleson is
semi closed
233
mapleson spontaneous best
All Dingos Can Breathe
234
abg and co2
down T then more CO2 dissolved in blood. pH up and pO2 down
235
bp only carotid pulse
systolic 60
236
bp carotid and femoral pulse
sup 70
237
radial pulse bp
80 if feel
238
pulse pressure by body part
more farther from heart
239
ohms law
V=IR
240
which current is more harmful
AC is x3 more dangerous
241
where needle goes for cervical plexus block
posterior border of SCM at its midpoint
242
stellate ganglion block location
medial to carotid pulse, anterior to c6 transverse process(vertebral artery protected)
243
brachial plexus nerves
C5-T1
244
brachial artery canulation can hurt what nerve
median
245
what sciatic splits to
common peroneal and tibial n
246
ankle block nerves
4/5 from sciatic: post tibial, sural, superficial and deep peroneal. other is saphenous from lumbar plexus
247
henry
concentration of gas dissolved in a solution is proportional to the partial pressure x solubility
