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Cardiac monitoring and cardiac drugs Flashcards

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1
Q

Indications for 5-lead EKG

A

-Diagnosis of dysrhythmias
-Diagnosis of ischemia
-Diagnosis of electrolyte disturbances
-Monitor effect of cardioplegia during aortic cross-clamp

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2
Q

What single lead is best to monitor the LV?

A

V5
Positioned along the anterior axillary line in the fifth intercostal space

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3
Q

90% of ischemic episodes will be detected by ECG if which 2 leads are viewed?

A

Lead II and V5

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4
Q

Subendocardial ischemia results in:

A

ST segment depression

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5
Q

transmural myocardial ischemia is detected as:

A

ST segment elevation

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6
Q

Coronary perfusion occurs when in the RV?

A

Systole and diastole

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7
Q

Coronary perfusion occurs when in the LV?

A

Diastole only

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8
Q

Mechanically the_________ is subjected to higher pressures than the_______

A

endocardium

epicardium

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9
Q

Arterial catheter indications:

A

-CT/CV surgery
-Major vascular
-Neurosurgery
-trauma
-Major abdominal
-solid organ transplant
-acid-base/electrolyte monitoring
-Dysrhythmias
-Marked obesity
-CPB
-LVAD

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10
Q

BP is measured at the level of the transducer which is where?

A

Level of Right atrium

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11
Q

On the arterial wave form, what does the area under the curve represent?

A

MAP

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12
Q

Dicrotic notch=

A

closure of aortic valve

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13
Q

Hypovolemia is suggested by a decrease in _____ ______ ____ with positive-pressure ventilation (pulsus paradoxus).

A

arterial systolic pressure

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14
Q

Respiratory variation of what 3 things can be used as goal-directed parameters to identify patients who will respond to fluid administration

A

arterial sBP

stroke volume (SV)

pulse pressure

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15
Q

Overdamped:

A

falsely underestimates systolic BP and overestimates diastolic BP

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16
Q

Underdamped:

A

falsely overestimates systolic BP and underestimates diastolic BP

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17
Q

How many oscillations during a square wave test will an optimally damped aline produce?

A

1-2

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18
Q

How many oscillations during a square wave test will a underdamped aline produce?

A

> 2

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19
Q

How many oscillations during a square wave test will an overdamped aline produce?

A

< 1.5

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20
Q

Factors for over dampened arterial waveform

A

Air within a catheter or transducer causes most pressure monitoring errors.

-Friction in the fluid pathway

-Bubbles in the tubing

-Clots in the tubing

-Vasospasm

-Long, narrow tubing (i.e. extensions added)

-Compliant tubing
make sure that pressure tubing is used if extension is required (do not use IV extension tubing)

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21
Q

Factors for under dampened arterial waveform

A

Catheter whip or artifact

Stiff non-compliant tubing

Hypothermia

Tachycardia or dysrhythmia

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21
Q

Factors for under dampened arterial waveform

A

Catheter whip or artifact

Stiff non-compliant tubing

Hypothermia

Tachycardia or dysrhythmia

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22
Q

Contraindications for a CVC

A

(a)Presence of significant carotid disease

(b)Recent cannulation of the IJ (with the concomitant risk of thrombosis)

(c)Contralateral diaphragmatic dysfunction

(d)Thyromegaly or prior neck surgery

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23
Q

What is the most common access route for CVC placement?

A

Internal Jugular (right)

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24
What are the locations you can put a CVC?
The IJ veins, subclavian (SC) veins, femoral veins
25
Blood flowing away from an ultrasound transducer is
BLUE
26
Blood flowing toward an ultrasound transducer is
RED
27
Disadvantage of using the subclavian vein for CVC placement?
Subclavian vein cannulation carries the highest rate of pneumothorax of any approach.
28
What is a risk of left sided subclavian vein CVC placement?
the thoracic duct may be lacerated
29
What approach is recommended as the first option for a PAC placement?
Right IJ
30
Distance to the junction of the vena cava and RA from subclavian
10cm
31
Distance to the junction of the vena cava and RA from Right IJ
15cm
32
Distance to the junction of the vena cava and RA from Left IJ
20cm
33
Distance to the junction of the vena cava and RA from femoral vein
40cm
34
Distance to the junction of the vena cava and RA from right median basilic vein
40cm
35
Distance to the junction of the vena cava and RA from left median basilic vein
50cm
36
Tip of CVP catheter should be placed just above what?
junction of vena cava and RA
37
Tip of PA catheter should be placed where?
pulmonary artery
38
Distance from right IJ to Junction of vena cava and RA
15cm
39
Distance from right IJ to right atrium
15-25cm
40
Distance from right IJ to right ventricle
25-35cm
41
Distance from right IJ to pulmonary artery
35-45cm
42
Distance from right IJ to pulmonary artery wedge position
40-50cm
43
Complications while floating a PA/Swan
Dysrhythmias while obtaining access Floating PA catheter: -Pulmonary artery rupture -Dysthymias -RBBB -->complete HB (DO NOT float a PAC into a patient with LBBB, advancing to RV can cause RBBB leading to complete HB)
44
What does the central venous pressure (CVP) measure
right atrial pressure
45
What does the CVP act as a predictor of?
Pt preload and volume status
46
Normal CVP range
1-10
47
what is CVP a good indicator of?
1. Intravascular volume 2. Venous tone 3. RV compliance ** not a good indicator of fluid status
48
A wave
Right atrial contraction just after P wave (atrial depolarization)
49
C wave
Right ventricular contraction Just after QRS (ventricular depolarization) (in line w S) closure of the tricuspid valve
50
X descent
Right atrial relaxation ST segment
51
X descent
Right atrial relaxation ST segment
52
V wave
passive filling RA Just after T wave begins ( ventricular repolarization) (coincides with part of RV systole)
53
Y descent
RA empties through open TV After T wave
54
Loss of a waves/only v waves:
Atrial fibrillation Ventricular pacing in the setting of asystole A wave occurs when synchronized contraction of RA is lost
55
Giant/ “cannon” a waves:
Junctional rhythms Complete AV block PVCs Ventricular pacing Tricuspid or mitral stenosis Diastolic dysfunction Myocardial ischemia Ventricular hypertrophy atria contracts and empties against a high resistance (either @ valve or noncompliant ventricle)
56
Large V waves:
Tricuspid regurgitation Acute increase in intravascular volume RV papillary muscle ischemia tricuspid regurg allow a portion of the RV volume to pass through a closed but incompetent tricuspid valve during RV systole. This increases pressure and volume in the right atria =  large V wave (C +V waves may blend together)
57
High CVP value:
RV failure Tricuspid stenosis OR regurgitation Cardiac tamponade Constrictive pericarditis Pericarditis Volume overload Pulmonary HTN PEEP Transducer below phlebostatic axis
58
Low CVP value
Hypovolemia ARDS Transducer above phlebostatic axis
59
CVP should be zeroed at the:
phlebostatic axis (4th intercostal space mid anteroposterior level)
60
CVP should be measured at
end expiration
61
PAC normal systolic value
Systolic: 20-30 mmHg
62
PAC normal diastolic value
8-12 mmHg
63
where should the tip of the PAC be?
Zone 3 = continuous blood flow -Provides most accurate estimate of LVEDP
64
Causes of high PA pressures
LV failure Mitral stenosis or regurgitation L-R shunt ASD or VSD Volume overload Pulmonary HTN Catheter “whip” catheter may be coiled or advanced too far
65
Causes of low PA pressures
Hypovolemia May see with RV failure May see with tricuspid regurgitation or stenosis
66
What is the pulmonary artery wedge pressure or PAOP measuring?
left ventricular end-diastolic pressure (LVEDP)
67
Why is a PAOP not commonly monitored?
due to increased risk of vessel rupture when wedging is performed incorrectly/catheter is not in the ideal position
68
Normal PAOP value
8-12 mmHg Or 5-15
69
what else can you use to estimate a wedge pressure?
PAD
70
what else can you use to estimate a wedge pressure?
PAD
71
Causes of a high wedge pressure
LV failure Mitral stenosis or regurgitation Cardiac tamponade Constrictive pericarditis Volume overload ischemia
72
Causes of a low wedge pressure
Hypovolemia RV failure Tricuspid regurgitation or stenosis Pulmonary embolism
73
normal CO
5-6 L/m
73
normal CO
5-6 L/m
74
How many injections should you do for accuracy of CO measurement via thermodilution method?
3
75
The area under the curve is _______ proportional to cardiac output
INVERSELY
76
Overestimates of CO using thermodilution
Low injectate volume Injectate that is too warm Thrombus on the thermistor of the PA catheter Partially wedged PA catheter
77
Underestimates of CO using thermodilution
Excessive injectate volume Injectate solutions that are too cold
78
Where do you need blood returning from to measure a SVO2 (mixed venous oxygen saturation)
SVC IVC coronary sinus 3 samples mix in pulmonary artery
79
Normal SVO2
mal SVO2 = 65-75%
80
SVO2 decrease caused by increased O2 consumption:
Stress Pain Thyroid storm Shivering Fever Seizure
81
SVO2 decrease caused by decrease o2 delivery
↓ Pao2 ↓ HBG ↓ C.O.
82
SVO2 increased d/t decreased o2 consumption
Hypothermia Cyanide toxicity-(SNP, sepsis, left to right shunt)
83
SVO2 increased d/t increased o2 delivery
↑ Pao2 ↑ HBG ↑ C.O.
84
Indications for TEE
-Identify systolic wall motion abnormalities (SWMA) and vascular aneurysms -calculation of EF -ventricular preload -measurement of blood flow within the heart and across the valves
85
TEE probe is placed in the esophagus to a depth of?
approx. 35-40 cm from teeth
86
Posterior structures are displayed at_____ and anterior structures ______of the screen
top of screen at the bottom
87
Best single view for routine monitoring SWMA
Short axis at midpapillary level
88
TEE is the gold standard for assessing what?
myocardial function
89
What does SOAP stand for?
Suction, oxygen (and other gases), airway equipment, pharmacy
90
other monitors:
cerebral oximetry BIS monitor TEE Istat
91
Pts with HTN will display an exaggerated response to:
induction agents (more HoTN) and laryngoscopy (more extreme HTN)
92
Administering _______ or _______can decrease the hyperdynamic sympathetic response to laryngoscopy
beta blockers arterial dilators (nitro)
93
Why would you use lidocaine IV prior to intubation?
Blunt laryngeal reflex with intubation
94
Predictors of hypotension during induction:
are age >50 ASA 3-4 baseline MAP <70 coadmin of high doses of fentanyl
95
metabolism for etomidate
ester hydrolysis
96
What does etomidate act as to increase the BP?
Alpha 2B adrenoceptor agonist
97
what does etomidate inhibit?
11b hydroxylase--> leads to adrenocortical suppression bc it's essential in the body's production of corticosteroids and mineralcorticoids
98
The effects of a single etomidate dose can last for how many hours?
72 hours
99
etomidate can cause increases in morbidity and mortality in patients who are:
on prior corticosteroid therapy and/or patients in a septic state
100
When is etomidate contraindicated?
Known sensitivity Adrenal suppression acute porphyrias
101
What is acute intermittent porphyria?
metabolic disorder caused by deficiencies in the enzymes that produce heme (building block of hemoglobin)
102
Most common symptoms of acute intermittent porphyria?
abdominal pain N/V
103
MOA of ketamine:
noncompetitive NMDA antagonist inhibits glutamate; depressant effect on thalamic nuclei —> this blocks afferent signals of pain perception to the thalamus and cortex
104
MOA of ketamine:
noncompetitive NMDA antagonist inhibits glutamate; depressant effect on thalamic nuclei —> this blocks afferent signals of pain perception to the thalamus and cortex
105
What does ketamine inhibit?
tumor necrosis factor alpha: may be responsible for its anti-inflammatory and antihyperanalgesic effects
106
what is the active metabolite of ketamine? What is it's active percentage?
Norketamine (20-30%)
107
what kind of waves does ketamine cause on EEG?
theta
108
How can you combat the increasing effect ketamine has on on CBF, CMRO2 and ICP?
administer GABA agonist
109
Primary effects of Precedex are
sedation analgesia anxiolysis reduced post-op shivering and agitation CV sympatholytic actions
110
What will happen if you bolus dexmedetomidine too fast?
HTN and tachycardia
111
*Mu effects
Respiratory depression bradycardia sedation euphoria miosis (pupillary constriction) urinary retention N/V pruritus
112
*Delta effects
Respiratory depression urinary retention pruritus
113
Kappa effects
Possible respiratory depression sedation dysphoria (state of unease) hallucinations delirium miosis diuresis anti-shivering
114
complications of vasopressin
GI ischemia decreased cardiac output digital necrosis cardiac arrest at elevated doses
115
*Which med causes increased coronary artery perfusion due to increase in diastolic BP
norepinephrine
116
Which med is typically a first line pressor when needed in a cardiac case?
Norepinephrine
117
MOA for dobutamine
*Primarily a beta 1 agonist with some B2 effects
118
what is the indication for dobutamine
increase CO/CI esp when coming off pump
119
Milrinone MOA
*phosphodiesterase 3 inhibitor; prevent the breakdown of cAMP
120
What does milrinone decrease?
preload AND afterload
121
What does Hemoptysis while floating a swan indicate?
PA RUPTURE
122
insertion site with the highest risk of injuring thoracic duct
Left IJ (can happen w left subclavian)
123
what is the risk of inserting a swan in the subclavian?
pneumothroax
124
why is LBBB a contraindication for PA catheter
RBBB= complete heart block
125
CVP should be measured at:
4th ICS mid anteroposterior level (phlebostatic axis)

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