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Mar: Sem 4 - Principles II > Exam 1: Cardiac Monitoring > Flashcards

Exam 1: Cardiac Monitoring Flashcards

1
Q

What is shown on this EKG?

A

Right BBB (use the “turn signal” method on V1 only)

S9

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2
Q

What is shown on this EKG?

A

Left BBB (“turn signal” goes down)

S10

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3
Q

What is indicated by the pink highlighted portion of the P wave below?

A

Right Atrial Hypertrophy
- Initial component of P is larger in V1
- Height is > 2.5mm in any limb lead

S11

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4
Q

What is indicated by the blue highlighted portion of the P wave below?

A

Left Atrial Hypertrophy
- Terminal portion of diphasic P in V1 is larger
- occurs with mitral stenosis and systemic HTN

S12

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5
Q

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

A

Bi-atrial enlargement

S12

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6
Q

What is indicated in this EKG?

A

RV Hypertrophy
- RV wall is thick therefore we have more depolarization toward V1
- QRS in V1 positive - R waves get smaller

not on the slide: but we also see more negative deflection in lead I - indicating the current travels more right

S13

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7
Q

What is this EKG showing?

A

LV hypertrophy
- Large S wave V1; Larger R wave V5
- depth of V1 and height of V5 = 35mm

S14

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8
Q

What EKG sign would be indicative of myocardial ischemia? (ischemia, not infarction)

A

Inverted symmetrical T-waves
- caused by a reduced supply of O2 from the coronary arteries

S15

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9
Q

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

A

Pathological Q-waves: 1mm wide or ⅓ the height of R-wave in 2 related leads.

S17

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10
Q

Cardiac pacemakers are the treatment for choice for?

A
  • Elderly or SSS
  • anti-bradycardi treatment (either from pathology or medication)
  • (often required temporarily after cardiac surgery)

S19

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11
Q

3 types of pacemakers and what do they consist of?

A
  • Transthoracic, transcutaneous and transvenous
  • Consists of pulse generator and electrode leads

S19

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12
Q

What type of pacemaker is most sensitive to electromagnetic interference?

A

Unipolar
- unipolar leads are negative eletrodes in chamber with the postitive (grounding electrode)

S20

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13
Q

What is the bipolar electrode?

A

both electrodes in chamber being paced

S20- Uses less energy; common

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14
Q

Do Bipolar or Unipolar pacemakers utilize less energy?

A

Bipolar uses less energy (more efficient)

most common

S20

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15
Q

What are the multipolar leads?

A

multiple electrodes within 1 lead but multiple chambers (some leads cross the septum - biatrial or biventricular)

S20

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16
Q

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

A

Bipolar Cautery

Lecture

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17
Q

In what situations would Bi-ventricular pacemakers be utilized?

A

Anywhere were resynchronization therapy is indicated.

  • HF (30-35% EF)
  • BBB
  • Hx of cardiac arrest

S25

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18
Q

Bi-Ventricular pacing has leads where?

A
  • RA
  • RV
  • LV (these are trans-septal)

S25

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19
Q

Purpose of Bi-Ventricular pacing

A

Cardiac resynchronization (CRT)
- improves RV-LV activation time
- increases EF

S25

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20
Q

What is the I generic code for pacemaker function and the possible modes

A

I indicate the chambers paced
- 0=no chamber paced
- A = atrium paced
- V = ventricular paced
- D = dual chamber paced

S21

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21
Q

What is the II generic code for pacemaker function and the possible modes

A

II indicate the chamber sensed
- 0 = none
- A = Atrium
- V = Ventricle
- D = dual sensed

S21

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22
Q

What is the III generic code for pacemaker function and the possible modes

A

III indicate the response to the sensing
- 0 = none
- T = triggered i.e. the pacer is triggered to act based on the sensing
- I = inhibited i.e. the pacer does not act based on the sensing
- D = dual (most common) will both trigger and inhibit

S21

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23
Q

What is the IV generic code for pacemaker function and the possible modes

A

IV indicates rate modulation of the pacer
- 0 = no rate modulation
- R = there is rate modulation

S21

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24
Q

What is the V generic code for pacemaker function and the possible modes

A

V indicates if there is multisite pacing
- 0 = none
- A = atrial
- V = ventricle
- D = Dual

S21

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25
What is the difference between Inhibited and triggered pacemaker mode?
- Inhibited: if intrinsic activity is perceived, chamber is not paced - Triggered: pacemaker discharges if intrinsic activity IS sensed; used currently only for testing of devices | S22
26
Magnets will make the Pacemaker default into what mode? (older models)
Asynchronous pacing with no rate modulation - DOO vs VOO - this might produce no change in pacing - Detects battery life response (decreases pulse amplitude or width) *Therefore we sometimes have inadequate capture* | S27
27
Perioperative care of AICD and BiV
- Optimize patient condition - Turn filter OFF on cardiac monitor - Want Bipolar cautery instead of monopolar - Back-up pacing ability - Interrogation postoperatively *Consider transQ pads if device isn't working* | S28
28
What is an AICD?
Inplantable Cardioverter-Defibrillator - battery powered to terminate VF or VT - it measures R-R intervals - if the R-R are too short, sometimes it can shock like in SVT (10% inappropriate) | S29
29
Criteria for an AICD shock
- Onset abrubt or gradual - VT/VF - R-R interval too short (SVT) - Variable or consistent R-R interval - QRS could be normal or wide | S29
30
What is a CVP?
- Pressure measured at the junction of vena cava and right atrium (Highly dependent on blood volume and vascular tone) - Used for assessment of blood volume and RIGHT heart function (trends instead of 1 number) - normal, awake, spont breathing = 1-7mmHg | S32
31
What causes an (a) waveform on a CVP?
- Atrial contraction - occurs after the P wave on EKG - increases atrial pressure - Provides the atrial kick | S34
32
What causes the (c) waveform on a CVP?
- Interrupts the decreasing atrial pressure - Isovolumetric contraction of the ventricle - Tricuspid valve closed and **ventricle bulges toward the atria** - Follows “R” wave | S35
33
What causes the x descent on the CVP?
- Decrease in atrial pressure from a wave through ventricular systole - called **systolic collapse** - sometimes called X and X1 | S36
34
What causes a (v) waveform on a CVP?
- Venous filling of the atrium - during late systole - when **tricuspid valve is still closed** - peaks just after T wave on EKG | S37
35
What causes the Y descent on the CVP?
- Tricspid valve opens - called **diastolic collapse** | S38
36
An h-plateau occers immediately before the ____ wave.
a-wave | Schmidt
37
The y descent happens after the ______ wave.
v-wave | S38
38
What is the H-wave or H-plateau?
Diastolic plateau (*not a lot of blood movement until atria contract to produce the a-wave*) | From Schmidty
39
The x descent happens after the ________ wave
c-wave | S38
40
During atrial fibrillation, loss of the ___ wave and enlargement of the ___ wave occurs to the CVP waveform.
- loss of A-wave - enlargement of C-wave | S39
41
What characteristics are seen on a CVP waveform in a patient with significant tricuspid regurgitation?
- Tall Systolic C-V wave - Loss of X-descent *Very similar to RV waveform* | S39
42
What characteristics are seen on a CVP waveform in a patient with significant tricuspid stenosis?
- Tall A-wave - Small Y-descent | S39
43
Describe a Swan-Ganz Catheter in detail. *Flip for picture*.
| S40
44
What does each lumen do in the PA catheter?
- Most distal: monitors PAP - 30cm proximal: monitors CVP - 3rd lumen: leads to the balloon to wedge the PA - 4th lumen: lies just proximal to the balloon, also has the termperature thermistor | S41
45
What is the preferred site for PA catheter placement?
Right IJ | S42
46
Where is the PA catheter at based on the waveform below?
Right Atrium | S42
47
Where is the PA catheter at based on the waveform below?
RV | S42
48
Where is the PA catheter at based on the waveform below?
Pulmonary Artery | S42
49
Where is the PA catheter at based on the waveform below?
Wedged | S42
50
What is the total length of the PA catheter?
110 cm marked at 10cm intervals | S43
51
Normal PAC depth for: - RA - RV - PA - Wedge
- RA: 20-25cm - RV: 30-35cm - PA: 40-45cm - Wedge: 45-55cm | S43
52
7 Complications of PAC
- Dysthythmias (PACs, PVS, VT runs) - RBBB or complete HB - Catheter knots - Pulmonary infarction - Pulmonary artery rupture - Endocarditis - Valve Injury VERB DIK | S44
53
What PA catheter complication is associated with very high mortality? What are the presenting s/s?
Pulmonary artery rupture - Hemoptysis (Bright red and copious) - Hypotension | S44
54
How are PA ruptures treated?
- ↑ Oxygenation - ETT (might need double lumen) - PEEP (to tamponade bleeding - very temporary) - Reverse anticoagulation (unless on bypass) - Tamponade bleed w/ PA balloon maybe - Definitive surgical repair *Thoughts and prayers* | S45 ## Footnote Cannot reverse anticoag while on bypass r/t pt will be "deader than dead" -Corn 8/3/24
55
How do you take a PAWP?
- this is an indirect measurement of LA pressure - PA diastolic can be used as an alternative (but issues with that too) - PAC tip should be in **West Zone 3** | S46
56
What are the drawbacks of estimating the wedge pressure with the LVEDP?
- Poor estimate of: - Compliance - Aortic regurgitation (artificially increases) - PEEP (artificially increases) - VSD (ventricular septal defect) - Mitral stenosis/regurg (weird wave) | S47
57
What would a PAC/CVP waveform look like in a patient with mitral regurgitation?
- **Tall V-wave** - C & V wave fused - No X-descent | S48
58
What would a CVP waveform look like in a patient with mitral stenosis?
- Slurred, early Y-descent - A wave may be absent d/t frequent association with a-fib | S49
59
How will the PA catheter waveform present with an acute LV MI?
- Tall A-waves d/t non-compliant LV - Increased LVEDV & LVEDP - PAWP increases | S50
60
The Mixed venous equation is a rearrangement of the ____ equation, and the equation is ____
Rearrangement of the Fick equation | S51
61
What is the typical range for mixed venous O₂ saturation and what is the O2 carrying capacity of Hgb?
- 70 - 80 % (*average 75*) - 1.34 | S54
62
What is the typical range for SVR?
800 - 1600 dynes/sec/cm5 (*average1200*) | S54
63
What is the typical range for PVR?
40 - 180 dynes/sec/cm5 (*average 80*) | S54
64
What is the typical range for stroke volume?
60 - 90 mL (*average 75*) | S54
65
What is bolus thermodilution for the PAC and what is it measuring?
- Cold injected (10ml) and measure a change in temperature downstream - Injected RA lumen, measured PA blood by thermister - 3 averaged attempts We measure CO: **CO inversely proportionate to degree of change** Subsequent changes of 13% significant | S55
66
What would the following cardiac output thermodilution curve indicate?
Low CO (Longer time to return to baseline) | S56
67
What would a high cardiac output thermodilution curve look like?
| S56
68
Examples of things that would cause thermodilution inaccuracies
- Measures right heart; assumes left heart we run into problems with the following: - Intra-cardiac shunts - Tricuspid/pulmonic regurgitation - Mishandling of the injectate (person dependent) - Fluctuations in temperature of the pt i.e. Following bypass - Rapid fluid infusion (Cold blood? cold meds going in?) | S57
69
How is continuous cardiac output measured?
- Small quantities of heat are released from filament in RV (measured at thermistor) - Updated q 30-60 seconds; averaged over 3-6 minutes - Compared to thermodilution: - Reproducibility/precision better - **But we have delay in updated information in unstable patients** ***More accurate during positive pressure*** | S58
70
If SVV is > ____% then patient is likely to respond well to fluids for hypotension.
10% *this relys on an algorithm from end diastole to end systole - and calculates ventricular compliance (+/- 0.5L/min compared to thermodilution)* | S59
71
Continuous Cardiac output monitoring and pulse contor inaccuracies
- Atrial fibrillation - Site of arterial puncture - Quality of arterial trace (Affected by vasopressors) - Requires frequent re-calibration (Ideally calibrated initially with a known CO) | S60
72
How many "views" are in a full echocardiogram?
28 views | S63
73
What five views can be utilized for a focused TTE?
1. Parasternal Long Axis 2. Parasternal Short Axis 3. Apical Four Chamber 4. Subcostal Four Chamber 5. Subcostal IVC | S65
74
What is assessed with a parasternal long-axis view?
- Overall Function - LA, LV and aortic root | S64
75
What is assessed with a parasternal short-axis view?
- LV function & volume status | S64
76
What is assessed with an apical four chamber view?
- RV vs LV size - Tricuspid & Mitral function - Descending Aorta | S64
77
What is assessed with a subcostal four chamber view?
- Pericardial Effusion often next to right heart - Four chambers | S65
78
What is assessed with a Subcostal IVC view?
IVC - Diameter - Collapsibility (especially in spont respiration) | S65
79
What are the two main contraindications to intra-operative TEE?
- Esophageal Varices - Lap Banding | S66

Mar: Sem 4 - Principles II (27 decks)

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