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Question 1

biomarkers for MI timeline

Answer 1

Troponin I or T – specific for cardiac injury, but not mechanism; peaks at 24 hr and elevated 7-8 days; relates to mortality

CPK-MB – positive earlier in 4-6 hr and back to normal in 24 hr; useful to check for possible recurrent MI within 1 wk since troponin will still be elevated

Myoglobin – earliest, but very nonspecific and not useful

AST and LDH – rise at 24 and 48 hr respectively

Question 2

pressure control- what do you set and what do you measure?

Answer 2

• set RR, PEEP, inspiratory pressure, pressure support, FiO2

* measure TV

Question 3

volume control- what do you set and what do you measure?

Answer 3

• set RR, PEEP, TV, FiO2

* measure pressure- peak pressure and plateau pressure

Question 4

If pH is high and CO2 low: what is it and what settings should you change

Answer 4

• resp alk Change RR, TV, or inspiratory pressure

Question 5

If low O2 on ABG, what settings should you adjust

Answer 5

• change FiO2 or PEEP

Question 6

If on SIMV pressure control and pH is high:

Answer 6

• check TV. If TV high, change pressure. If TV nl, change RR.

Question 7

which leads affected in anterior MI?

Answer 7

o Anterior – V3, V4; right coronary artery

Question 8

which leads affected in inferior MI

Answer 8

Inferior – II, III, AVF; right coronary artery

Question 9

whicih leads affected in lateral MI

Answer 9

Lateral – I, AVL, V5, V6; circumflex

Question 10

which leads affected in septal MI?

Answer 10

Septal – V1, V2; LAD

Question 11

dose of morphine for MI

Answer 11

morphine sulfate 2-4 mg IV q 5-15 min PRN initially, up to 8 mg max; treats pain only; contraindicated in shock

Question 12

do you give thrombolytics for NSTEMI?

Answer 12

no

Question 13

do you give IVF to cardiogenic shock?

Answer 13

no –> Pulm edema

Question 14

Typical pulmonary capillary wedge pressure is

Answer 14

8-16

Question 15

Normal PVR

Answer 15

< 250

Question 16

Normal mixed venous PO2

Answer 16

40mmHg, which is a saturation of 75%.

Question 17

fluid orders for shock

Answer 17

Fluid bolus with normal saline or lactated ringers, 500 ml q 5 min

Question 18

nl CO value

Answer 18

5 L/min

Question 19

Nl SVR

Answer 19

800-1200

Question 20

How is cardiac output determined?


Answer 20

Using a Swan-Ganz, cold saline is injected in RA, temp measured in pulm capillary bed, area under curve analyzed

Question 21

What information is gained by measuring the PCWP?


Answer 21

pressure in the L atrium and helps determine the function of the L heart

Question 22

Describe situations in which the PCWPmay provide misleading information

Answer 22

LVH, restrictive heart disease (sarcoidosis, amyloidosis, hemochromatosis), mitral stenosis, pulmonary veno-occlusive disease, high PEEP from mechanical ventilation can have normal or high LVED pressure (Pcwp) but low LVED volume; therefore, a low Pcwp is truly low, but a normal Pcwp may reflect normal or low volume


Question 23

What would be indications for placement of a SG catheter?


Answer 23

Cardiogenic shock, complicated CV surgery, combination of shock and ARDS


Question 24

pressure in pulm artery

Answer 24

20/10.

Question 25

role of corticosteroids during shock

Answer 25

many patients (up to 3/4) in shock have concurrent adrenal failure and replacing corticosteroids has a mortality benefi

Question 26

specific goals for CVP, MAP, Scv02 in septic shock

Answer 26

CVP = 8-12; ↑ with IVF


MAP = ≥ 65, ↑ with pressors (NE, then DA; increase until max, then add Epi)


ScvO2 ≥ 70% with Hgb ≥ 10, ↑ with supplemental O2 and pRBC


Question 27

SIRS criteria

Answer 27

– 2/4 of following: 
HR > 90; 
RR > 20 or PaCO2 < 32; 
WBC > 12 or < 4 or > 10% bands; 
Temp > 100.4 (38 C) or < 98.6 (36 C)


Question 28

severe sepsis

Answer 28

sepsis + end organ damage such as:

• ARDS (PaO2/FiO2 < 300),
• encephalopathy (GCS ≤ 11 or drop ≥ 3),
• coagulopathy (Plt < 80 or > 50% drop, INR >2, DIC),
• ↑indirect bilirubin,
• RF (CR > 2x nl, ↓ or no UOP),
• HF (needs vasopressors, ↑ lactate, cap refill > 5 sec)

Question 29

therapies for cardiogenic shock

Answer 29

Do tPA, PCI, CABG or intraaortic balloon pump (IABP

Question 30

therapies for septic shock

Answer 30

IVF (4-10L),
start NE, can then use vasopressin if that does not work
assess for use of steroids
methylene blue