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How far is an esophageal stethoscope inserted into the esophagus?

28-30cm. This allows us to hear heart sounds and BS internally.


What are precordial and esophageal stethoscopes useful for?

Continuous assessment of heart and breath sounds. Very sensitive monitor for bronchospasm and changes in pediatric patients


How often should we have a regular stethoscope available?

At all times


What 4 general things are continually evaluated?

Oxygenation, ventilation, circulation, and temperature


Considerations in deciding what type of monitoring to use

1) Indication
2) Risk/benefit
3) Complications
4) Alternatives
5) Cost
6) Skill level


Types of hemodynamic monitoring used

EKG, BP (NIBP and IABP), CVP, PAP, PCWP, TEE, stethoscope


What can the EKG tell you?

Heart rate, arrhythmias, Ischemia, electrolyte imbalances, pacemaker function


Aspects of the 3 Lead EKG

Electrodes used: RA, LA, LL
Leads: I, II, III
Number of views of the heart: 3


Aspects of the 5 lead EKG

Electrodes used: RA, LA, RL, LL, chest
Leads: I, II III, AVL, AVR, AVF, V lead
Number of views of the heart: 7


Value of the length and width of each EKG box

.1mV and .04s


How to calculate HR based on EKG lead

1500/# boxes between R waves


How should the gain be set in order to accurately assess the ST segment?

At standardization (1mV signal gives a rise of 10mm). This setting also fixes the ratio of the QRS complex to the ST segment size so that a 1mm change in the ST segment can be accurately assessed. If the wrong gain setting is used, ST changes may be under or over-diagnosed.


What filtering mode should the EKG be on for accurate ST assessment?

Diagnostic mode. Filtering out the low end of frequency bandwith (which can happen on monitor mode) can lead to ST distortion (either elevation OR depression)


5 main indicators of acute ischemia

ST elevation ( >1mm), ST depression ( >1mm), flipped Ts, peaked Ts, development of Q waves


Posterior / inferior wall ischemia is seen in these leads and is due to a blockage in this artery

Right coronary


Lateral wall ischemia is seen in these leadsand is due to a blockage in this artery

I, AVL, V5-6
Left circumflex coronary artery


Anterior wall ischemia is seen in these leadsand is due to a blockage in this artery

I, AVL, V1-4
Left coronary artery


Anterioseptal wall ischemia is seen in these leads and is due to a blockage in this artery

Left anterior descending coronary artery


This part of BP correlates to the point of the most demand on the heart



The pulse pressure changes as you move from where to where

From the central arterial system to the periphery. The pulse pressure widens due to wave reflections in the vasculature.


These factors can cause a falsely high NIBP reading

Cuff too small, cuff below the level of the heart, loose cuff, arterial stiffness (HTN, PVD)


These factors can cause a falsely low NIBP reading

Cuff too large, cuff above the level of the heart, poor tissue perfusion, deflation is too rapid


Fals NIBP reading can also occur with

Cardiac dysrhythmia, tremors/shivering/ and improper cuff placement


This type of NIBP reading only gives you SBP

Palpation. It measures the return of arterial pulse during deflation. This is simple, inexpensive, and underestimates the SBP.


This NIBP reading only gives you SBP but measures it fairly reliably

Doppler. Measures it by a shift in frequency of sound waves that is reflected by RBCs moving through an artery.


This NIBP method estimates both SBP and DBP

Auscultation with a sphygmomanometer. Measures BP by auscultation Karotkoff sounds created by turbulent blood flow though the artery created by the mechanical deformation from the BP cuff. This method is unreliable in patients with HTN.


Changes in SBP correlate with changes in ____

Myocardial O2 demand.


Automated cuffs work by this mechanism



Complications of NIBP measurement

Ulnar nerve damage, compartment syndrome, edema of the extremity, bruising / petechiae, pain, interference of IV flow, altered timing of IV drug administration


Indications for IABP monitoring

1) Deliberate hypotension
2) Risk of rapid BP changes
3) Wide swings in BP intra-op
4) Rapid fluid shifts
5) Titration of vasoactive drugs
6) End organ disease
7) Repeated blood sampling
8) NIBP measurement failure