Cardiac Monitoring (Exam I)

Question 1

How would a bundle branch block be distinguished right from left?

Answer 1

In V1 lead, find j-point and go backwards to QRS segment. If wave goes up = RBBB, if wave goes down = LBBB

Question 2

What is indicated by the pink highlighted portion of the EKG below?

Answer 2

Right Atrial Enlargement

long left, high right

Question 3

What is indicated by the blue highlighted portion of the EKG below?

Answer 3

Left Atrial Enlargement

long left, high right

Question 4

P-waves for lead II and Lead VI are shown below. What would be indicated by this EKG waveform?

Answer 4

Bi-atrial enlargement

Question 5

What EKG sign would be indicative of myocardial ischemia?

Answer 5

Inverted symmetrical T-waves

ischTemia

Question 6

What EKG sign would be indicative of non-salvageable tissue damage post acute myocardial infarction? (infarct)

Answer 6

Pathological Q-waves: 1mm wide or ⅓ the height of R-wave.

infarQt

Question 7

What type of pacemaker is most sensitive to electromagnetic interference?

Answer 7

Unipolar

Question 8

What part of a pacemaker device provides current and an energy source? What is exposed metal end in contact with the endocardium? What is the insulated wire inbetween these two parts?

Answer 8

• Generator
• Electrode
• Lead

Question 9

Do Bipolar or Unipolar pacemakers utilize less energy?

Answer 9

Bipolar uses less energy (more efficient)

Question 10

What’s the most common pacemaker?

Answer 10

Single lead → single chamber

Question 11

How is the function of a pacemaker explained in its name? (order)

Answer 11

Acronym Letters:

• 1st - Chambers paced
• 2nd - Chambers sensed
• 3rd - Response to sensing
• 4th - Rate modulation
• 5th - Multisite pacing

Question 12

What type of electrocautery is more safe for patients with permanent pacemakers?

Answer 12

Bipolar Cautery

Question 13

In what situations would Bi-ventricular pacemakers be utilized?

Answer 13

When resynchronization therapy is indicated.

• HF
• BBB
• Hx of cardiac arrest

Question 14

What is an ICD device?

Answer 14

Implantable Cardioverter-Defibrillator

• capable of terminating VF or Vtach
• measures R-R interval

Question 15

Label the a, c, & v waveforms on the Wiggers diagram below.

Answer 15

Question 16

What is a normal CVP value?

Answer 16

1-7 mmHg

Question 17

What causes an (a) waveform on a Wiggers diagram?

Answer 17

↑ CVP due to atrial contraction sending blood into ventricles and backwards.

Question 18

What causes the (c) waveform on a Wiggers diagram?

Answer 18

• Backward “bulging” of the tricuspid valve (from ventricular contraction) slightly displacing blood backwards.

Question 19

What causes a (v) waveform on a Wiggers diagram?

Answer 19

• Volume accumulating in the atria until opening of the tricuspid/mitral valves.

Question 20

What is the a-wave?

Answer 20

Atrial contraction

Question 21

What is the C-wave?

Answer 21

Backwards “bulging” of tricuspid valve in response to high ventricular pressures

Question 22

What is the V-wave?

Answer 22

Rapid filling of the atria

Question 23

What is the H-wave or H-plateau?

Answer 23

Diastolic plateau (not a lot of blood movement until atria contract to produce the a-wave)

Question 24

What is the X-descent or x-wave?

Answer 24

Steep drop in pressure as atria relax and start filling.

Question 25

What is the Y-descent or y-wave?

Answer 25

Tricuspid valve opens and atria fills the ventricles in early diastole

Question 26

An h-plateau occers immediately before the ________ wave.

Answer 26

a-wave

Question 27

The x descent happens after the ________ wave

Answer 27

c-wave

Question 28

The y descent happens after the ______ wave.

Answer 28

v-wave

Question 29

During atrial fibrillation, loss of the ___ wave and enlargement of the ___ wave occurs to the CVP waveform.

Answer 29

loss of A-wave, enlargement of C-wave (lost atrial kick, atria remains more full)

Question 30

What characteristics are seen on a CVP waveform in a patient with significant tricuspid regurgitation?

Answer 30

- Tall Systolic C-V wave - Loss of X-descent *Very similar to RV waveform* (blood leaks back into R atrium from RV contraction)

Question 31

What characteristics are seen on a CVP waveform in a patient with significant tricuspid stenosis?

Answer 31

- Tall A-wave - Attenuated Y-descent (increased backward pressure generated with atrial kick)

Question 32

Describe each portion of a Swan-Ganz Catheter.

Answer 32

Question 33

What is the preferred site for PA catheter placement?

Answer 33

Right IJ

Question 34

Where is the PA catheter at based on the waveform below?

Answer 34

Right Atrium (essentially CVP)

Question 35

Where is the PA catheter at based on the waveform below?

Answer 35

RV

Question 36

Where is the PA catheter at based on the waveform below?

Answer 36

Pulmonary Artery

Question 37

Where is the PA catheter at based on the waveform below?

Answer 37

Wedged

Question 38

What is the total length of the PA catheter?

Answer 38

110 cm

Question 39

What PA catheter complication is associated with very high mortality? What are the presenting s/s?

Answer 39

Pulmonary artery rupture - Hemoptysis (Bright red and copious) - Hypotension

Question 40

How are PA ruptures treated?

Answer 40

- ↑ Oxygenation - Double lumen ETT - PEEP (to tamponade bleeding) - Reverse anticoagulation - Tamponade bleed w/ catheter - Definitive surgical repair *Thoughts and prayers*

Question 41

What would a PCWP waveform look like in a patient with mitral regurgitation?

Answer 41

- **Tall V-wave** - C & V wave fused - No X-descent

Question 42

What would a PAWP waveform look like in a patient with mitral stenosis?

Answer 42

- Slurred, early Y-descent

Question 43

How will the PA catheter waveform present with an acute LV MI?

Answer 43

- Tall A-waves - Increased LVEDV & LVEDP - PAWP increases

Question 44

What is the typical range for SVR?

Answer 44

800 - 1600 dynes/sec/cm⁵

Question 45

What is the typical range for PVR?

Answer 45

40 - 180 dynes/sec/cm⁵

Question 46

What is the typical range for stroke volume?

Answer 46

60 - 90 mL

Question 47

What is the typical range for cardiac output?

Answer 47

4 - 6.5 L/min

Question 48

What is the typical range for mixed venous O₂ saturation?

Answer 48

70 - 80 %

Question 49

What would the following cardiac output thermodilution curve indicate?

Answer 49

Low CO (Longer time to return to baseline temp)

Question 50

What would a high cardiac output thermodilution curve look like?

Answer 50

Return to baseline temp quickly

Question 51

If SVV is > _____% then patient is likely to respond well to fluids for hypotension.

Answer 51

10%

Question 52

How many "views" are in a full echocardiogram?

Answer 52

28 views

Question 53

What five views can be utilized for a focused TTE?

Answer 53

1. Parasternal Long Axis 2. Parasternal Short Axis 3. Apical Four Chamber 4. Subcostal Four Chamber 5. Subcostal IVC

Question 54

What is assessed with a parasternal long-axis view?

Answer 54

- Overall Function - Left Heart and aortic root

Question 55

What is assessed with a parasternal short-axis view?

Answer 55

- LV function & volume status

Question 56

What is assessed with an apical four chamber view?

Answer 56

- RV vs LV size - Tricuspid & Mitral function - Descending Aorta

Question 57

What is assessed with a subcostal four chamber view?

Answer 57

- Pericardial Effusion - Four chambers

Question 58

What is assessed with a Subcostal IVC view?

Answer 58

IVC - Diameter - Collapsibility (especially in determining volume status)

Question 59

What are the two main contraindications to intra-operative TEE?

Answer 59

- Esophageal Varices - Lap Banding