Cardiovascular monitoring - Exam 2 Flashcards
(123 cards)
1
Q
Bipolar limb leads use __ electrodes and form ____ triangle
A
2, Einthoven’s
2
Q
Where do the following positive electrodes go:
AVR
AVL
AVF
A
AVR –> Right arm
AVL –> Left arm
AVF –> Left foot
3
Q
12 leads are useful in the identification of these 4 things:
A
-Rhythm
-Infection
-Conduction delays
-Damage
4
Q
Where are V1 and V2?
A
4th ICS on either side of the sternum
5
Q
What is this rhythm?
A
RBB
6
Q
Characteristics of a right BBB
A
-Conduction delay
-R/R1 (rSr pattern)
-QRS >0.12 seconds
7
Q
What is this rhythm?
A
LBB
8
Q
This type of bundle block may mimic the appearance of an acute anteroseptal MI
A
LBB
9
Q
What lead do we look at for bundle branch blocks?
What about atrial hypertrophy?
A
Lead V1
10
Q
Diagnosis of right atrial hypertrophy
A
-Initial component of P larger in V1
-Height > 2.5 mm in any limb lead
11
Q
Causes of right atrial hypertrophy:
A
all causes of LVH, LAE, and RVH
-Tricuspid valve disease
12
Q
Left atrial hypertrophy diagnosis:
A
-Terminal portion of diphasic P in V1 is larger
-Occurs with mitral stenosis, systemic HTN
13
Q
Left atrial hypertrophy causes:
A
All causes of left ventricular hypertrophy
Mitral valve disease
14
Q
With right ventricular hypertrophy, you will see more depolarization towards ___
A
V1
15
Q
Causes of right ventricular hypertrophy
A
Primary pulmonary pathology:
COPD
Pulmonary HTN
16
Q
With right ventricular hypertrophy, the QRS in V1 is ____ and the R waves get ____
A
positive, smaller
17
Q
With left ventricular hypertrophy, there is a large S wave in ___ and a larger R wave in ___
A
V1, V5
18
Q
With left ventricular hypertrophy the depth of V1 and height of V5 = ___ mm
A
35
19
Q
Causes of left ventricular hypertrophy
A
HTN, CHF, Aortic valve disease, Coarctation
20
Q
Myocardial ischemia involves an inverted, symmetrical __ wave in __ contiguous leads
A
T, 2
21
Q
With a myocardial injury, there is ST elevation in __ contiguous leads
A
2
22
Q
Myocardial infarct card -
Which wave on the EKG indicates an old infarct?
How big does this wave have to be to indicate old infarct?
In how many leads?
What happens to the R waves in MI?
A
23
Q
This is the tx of choice for disturbances in cardiac impulse conduction
A
Artifical cardiac pacemakers
24
Q
3 places cardiac pacemakers can be inserted / placed
A
-Transthoracic (needle/wire thru chest wall into heart)
-Transcutaneous (stickers)
-Transvenous (through IJ or subclav into heart)
25
Pacemaker Definitions:
Energy source and electrical circuits
Generator
26
Pacemaker Definitions:
Insulated wire from generator to electrode
Lead
27
Pacemaker Definitions:
Exposed metal end in contact with the endocardium
Electrode or epicardial leads
28
Pacemaker Definitions:
Negative electrode in chamber and positive electrode (grounding)
Unipolar
29
Unipolar pacemakers are more sensitive to
EMI
(Electromagnetic Interference)
30
This type of pacemaker (unipolar or bipolar or multipolar) is more common and uses less energy
Bipolar
31
Pacemaker Definitions:
both electrodes in chamber being paced
Bipolar
32
Pacemaker Definitions:
Multiple electrodes within 1 lead but multiple chambers
Multipolar
33
In the pacemaker code what does the first initial tell you?
Chambers paced
34
What do the following letters mean in the first and second initial of the pacemaker code?
O
A
V
D
O = none
A = atria
V = ventricles
D = dual (A + V)
## Footnote
First initial paced
Second initial is sensed
35
What do the following letters mean in the third initial of the pacemaker code?
O
T
I
D
Response to sensing:
O = none
T = triggered
I = inhibited
D = dual (T + I)
36
What does the fourth initial of the pacemaker code tell you?
What do the letters mean?
Rate modulation
O = None
R = Rate modulation
37
What does the fifth initial of the pacemaker code tell you?
What do the letters stand for:
O
A
V
D
Multisite pacing
O = None
A = atrium
V = ventricles
D = dual (A + V)
38
What does rate modulation mean in regards to pacemakers?
It is a setting that programs the pacemaker to adapt the firing rate in people who are physically active
39
Pacemaker codes:
Inhibited definition
If intrinsic activity is perceived, chamber is not paced
40
Pacemaker codes:
Triggered
When is this used?
pacemaker discharges if intrinsic activity IS sensed
Used currently only for testing of devices
41
What 4 things are involved in the rate modulation of a pacemaker?
Vibration
Motion
Minute ventilation
Right ventricular presure
42
In what 2 cardiac pathologies would we use multi site pacing
A fib
Dilated cardiomyopathies
43
3 things involved in the perioperative care of a PM
-Turn filter **OFF** on cardiac monitor “turn off artifact on the anesthesia machine”
-Grounding pad distant from PM “**thighs or butt** would be great” NOT arms or back!!!
-Interrogation pre / post op
44
Biventricular pacing involves __ chambers
Which ones?
3
Right atrium, both ventricles (trans-septal)
45
what two things does CRT (cardiac resynchronization) improve?
-EF
-RV-LV activation time
46
What are the requirements for biventricular pacing?
-Moderate / severe HF
-Intraventricular conduction delays
-NYHA class III or IV despite optimization
-History of cardiac arrest
47
Magnets and PM info
48
How does a magnet prevent innapropriate shocks from a PM?
Disables anti-tachycardia therapy
49
Perioperative care of AICD / BiV
-Optimize patient condition
-Turn filter OFF on cardiac monitor
-Bipolar cautery
-Back up pacing ability
-Interrogate post op
BOBIT
50
What two rhythms can ICDs terminate?
V tach
V fib
51
How do ICDS work?
They measure:
-R-R intervals
-Amplitude
-QRS width
-The onset (abrupt or gradual)
## Footnote
Vfib --> short amplitude
R-R interval --> fast for v tach; not much of one for v fib
52
In a normal person, is the carotid or IJ more medial?
Carotid
53
CVP is the pressure measured at the junction of the _____ and ___
vena cava, right atrium
54
For CVP measurements you need to know the distance from the insertion site to the junction. How many cm are the following from the insertion site?
Right subclavian:
Right IJ:
Left subclavian:
Left IJ:
Right subclavian: 14 cm
Right IJ: 15 cm
Left subclavian: 17 cm
Left IJ: 18 cm
55
CVP is highly dependent upon ___ and ___
-Blood volume
-Vascular tone
56
Normal CVP (in a patient who is awake and spontaneously breathing)
1-7 mmHg
57
8 indications for CVP lines
58
What does the "A wave" represent in CVP?
Where does it occur in regards to ECG?
Atrial contraction
After the P wave on ECG
## Footnote
Occurs at end diastole
59
What does the "C wave" represent in CVP?
Where does it occur in regards to ECG?
Isovolumic ventricular contraction, tricuspid/ventricular motion towards the right atrium
Follows the "R wave"
60
This CVP wave interrupts the decreasing atrial pressure
C wave
61
This CVP waveform component is called the systolic collapse
X descent
62
What does the "V wave" represent in CVP?
Where does it occur in regards to ECG?
Venous filling of atrium
Peaks just after the "T"
63
What does the "Y descent" represent in CVP?
Tricuspid valve opens --> early ventricular filling; diastolic collapse
64
What waveform component in CVP is known as the "diastolic collapse"
Y descent
65
What 3 pathologies can cause abnormal CVP waveforms (according to Kane)
-A fib
-Tricuspid regurgitation
-Tricuspid stenosis
66
What would the CVP waveform look like in someone with a fib?
-No A wave
-Larger C wave
67
What would the CVP waveform look like in someone with tricuspid regurgitation?
No x descent
68
What would the CVP waveform look like in someone with tricuspid stenosis?
-Tall a wave
-bigger Y descent
69
In the PA cath, which port monitors PAP?
Most distal
70
In the PA cath, which port monitors CVP?
30 cm proximal
71
Which PA cath lumen leads to a balloon near the tip?
3rd lumen
72
In the PA cath, which lumen lies proximal to the balloon and houses the thermistor?
4th lumen
73
When did Swan, Ganz and colleagues come out with the PA cath?
Who was it introduced for?
What is the preferred site?
1970
Assessment tool for MI patients
Right IJ
74
With a PA cath, the balloon is deflated until you reach the _____
Right atrium
75
Based on your PA cath wave form, where are you in image one?
Right atrium
76
Based on your PA cath wave form, where are you in image two?
Right ventricle
77
Based on your PA cath wave form, where are you in image three?
Pulmonary artery
78
Based on your PA cath wave form, where are you in image four?
Wedging a pulmonary artery
79
How long is the PA catheter?
It is marked at ___ cm intervals
110 cm length
10 cm intervals
80
Guidelines for PAC depth:
Right atria
20-25 cm
81
Guidelines for PAC depth:
Right ventricle
30-35 cm
82
Guidelines for PAC depth:
Pulmonary Artery
40-45 cm
83
Guidelines for PAC depth:
Wedge
45-55 cm
84
PA cath complications (7):
-Dysrhythmias
-RBB / complete heart block
-Catheter knots
-Pulmonary infarction
-Pulmonary artery rupture
-Endocarditis
-Valve injury
85
You put a PA cath in your patient and they have hemoptysis and hypotension, what do you expect?
Pulmonary artery rupture
86
Treatment of PA rupture
-Adequate oxygenation
-PEEP
-Reverse anticoags (unless on bypass)
-Float balloon into rupture vs. withdrawing catheter
-Surgical therapy
87
With PAC monitored pressures, PAWP should be measured with the PAC tip in zone __
3
88
What PA cath pressure is an indirect measurement of left atrial pressure?
PAWP
89
What things can impact your LVEDP
-Compliance
-Aortic regurgitation
-PEEP
-ventricular septal defect (VSD)
-Mitral stenosis / regurgitation
90
What abnormal PAC waveforms will you see with Mitral regurgitation
-Tall V wave
-C and V wave fused
-No x descent
91
What abnormal PAC waveforms will you see with Mitral stenosis?
-Slurred, early y descent
-A wave may be absent due to frequent associaiton with a fib
92
What abnormal PAC waveforms will you see with Acute LV myocardial MI
-Tall a waves due to non compliant LV
93
Mixed venous oximetry equation:
94
Why do we care about mixed venous oximetry?
Low venous saturation may signal anemia and a blood transfusion may be needed
95
Average:
CO
SV
Mixed venous O2 sat
CO: 5 L/min
SV: 75 ml
Mixed venous O2 sat: 75
96
Average:
SVR
PVR
1200 dynes/sec/cm5
80 dynes/sec/cm5
97
What is the gold standard but old way of measuring CO
Bolus thermodilution
98
Explain the steps of bolus thermodilution
1. 10 ml of cold fluid injected into RA lumen
2. The temp change is then measured downstream in the PA blood by the thermister
3. The CO is inversely proportionate to the degree of change
## Footnote
If CO sucks then temp will change greatly
99
With bolus thermodilution, there are ___ averaged attempts
Subsequent changes of ___% are significant
3
13%
100
Which thermodilution curve represents a low CO?
Middle pic
101
What things can cause thermodilution to be inaccurate?(5)
-Cardiac shunts
-T/P regurg
-Mishandling of injectate
-Temp fluctuations
-Rapid fluid infusion
102
This type of CO measurement involves small quantities of heat being released from filament in the RV
Continuous CO
103
Continuous CO is updated Q ___-___ seconds and averaged over __-__ minutes
30-60
3-6
104
Which CO measurement has better precision and reproducibility: Continuous CO or bolus thermodilution?
Continuous CO
105
Which CO measurement is more accurate during positive pressure: Continuous CO or bolus thermodilution?
Continuous CO
106
These devices use the area under the curve (AUC) arterial pressure tracings to estimate CO, pulse pressure and SVV
Pulse contour
107
What things can cause pulse contour inaccuracies?
108
This echo mode uses narrow beams to measure tissue planes such as ventricular wall mass
M-mode
(Motion mode)
109
This echo mode uses real time motion and shows us the function of the heart
2-D mode
110
This echo mode uses color and can determine speed and direction
Doppler
111
the FoCUS method of the TTE involves __ key views whereas a comprehensive exam involves __ views
5
28
112
With FoCUS, the ____ (anterior or posterior) structures are closest to transducer and shown at the ___ (top or bottom) of the image
Anterior
Top
113
What are the three FoCUS windows?
Parasternal (intercostal 3-5)
Apical (at point of maximal impact (PMI)
Subcostal (just below xiphoid)
114
Where do we look for the following windows:
Parasternal
Apical
Subcostal
Parasternal: 3-5 ICS
Apical: PMI (point of maximal impulse)
Subcostal: just below xiphoid
115
This FoCUS view is a great view. It measures LA, LV and Aortic root
Parasternal long axis
116
This FoCUS view lets us look at LV function and LV volume assessment
Parasternal short axis
117
This FoCUS view allows us to look at:
RV vs LV size
TV and MV function
Descending aorta
Apical four chamber
118
This FoCUS view allows us to visualize the 4 chambers and we are able to see a pericardial effusion often next to the right heart
Subcostal four chamber
119
This FoCUS view allows us to look at IVC diameter and collapsibility (esp in spontaneous respiration)
Subcostal IVC
120
Two contraindications to intraop TEE
Esophageal varices
Laparoscopic banding
121
With intraop TEE, the ____ (anterior or posterior) structures are closest to transducer and shown at the ___ (top or bottom) of the image
posterior
Top
122
Roles of intraoperative TEE
123
Aorta and aortica valve on echo (not a question just an FYI)
## Footnote
Looking for calcifications, if calcified, wouldn't want to stick trochar through there. Aorta more likely to split
