What are the three causes of thrombosis according to Virchow’s triad?
- Venous stasis
- Vessel wall injury (abnormal vessels)
- Hypercoagulability
What are the two causes of venous stasis?
- Immobility
2. Reduced flow
Deficiencies of what proteins can cause hypercoagulability?
Proteins C, S
Malignancy is a large risk factor for what two conditions?
DVT
PE
Which heart valve is accentuated during PE?
Accentuation of S2; closing of pulmonic valve
What lung sounds may you hear in patient with PE?
Pulmonary friction rub
Rales
What two values will plummet in presence of massive PE?
BP and end-tidal CO2 plummets
Which type of chest pain indicates PE?
Pleuralistic pain
What three inotropes would we use in event of PE to recover massive decrease in BP?
Isoproterenol
Dopamine
Dobutamine
When massive PE is unresponsive to medical management, what is our next line of action?
Pulmonary artery embolectomy with CPB
How will you monitor arterial and cardiac filling pressures to manage IVF administration and optimize RV stroke volume?
PA catheter
What effects may pulmonary hypertension have on the heart (blockage in or narrowing of pulmonary artery)
Right chambers may enlarge.
Blood is often forced backward through tricuspid valve
Mitral valve stenosis (narrowing)
What is a common phosphodiesterase inhibitor used to treat pulmonary hypertension?
Viagra
What increases right-sided HF?
Hypoxia, hypercarbia
What are the two best treatments for COPD?
Quit smoking
Supplemental O2
What are two methods of post-op care for COPD patients?
Lung volume expansion techniques
Post-op analgesia with neuraxial opioids
Result of previous RSV infection
Bronchiolitis Obliterans
Develops after prolonged intubation or tracheostomy
Tracheal stenosis
What is asthma?
Chronic airway inflammation defined by reversible expiratory airflow obstruction + airway hyperreactivity
What are two pathological features of asthma?
Airway wall inflammation
Luminal obstruction of airways
What causes luminal obstruction of airways in asthma?
Inflammatory cells and mucous
Under what condition would you see a patient sitting in tripod position to ease breathing?
Asthma–dyspnea, “air hunger”
What is principal treatment for asthma patients?
Inhaled corticosteroids, a type of antiinflammatory drug
What are the three types of drugs that can treat asthma?
Antiinflammatory drugs
Bronchodilator drugs
Methylxanthines
What type of medications should asthmatic patients avoid? Why?
NSAIDS; may be a trigger for attacks
What characterizes restrictive lung disease?
Decrease in total lung capacity
What causes restrictive lung disease?
An intrinsic disease process that alters the elastic properties of the lungs, causing the lungs to stiffen
What are four main causes of restrictive lung disease?
Acute intrinsic restrictive lung disease
Chronic intrinsic restrictive lung disease
Chronic extrinsic restrictive lung disease
Disorders of pleura and mediastinum
RLD causes TLC =
<80% of expected value
An increase in muscle mass is known as:
Hypertrophy
Dilation of a particular chamber is known as:
Enlargement
What leads immediately indicate whether or not heart axis is normal? What defines normalities?
Leads I and aVF–normal positive QRS complexes in these leads = normal axis
What degrees define a normal heart axis?
0-90*
If either lead I and aVF are negative, it indicates that:
axis is abnormal
Which leads overlie the right side of the heart?
II, III, aVF
Which portion of the P-wave is affected in left atrial enlargement?
2nd portion
Which type of atrial enlargement causes longer P-wave?
Left atrial enlargement
Which type of atrial enlargement causes longer P-wave?
Left atrial enlargement
Why does the left atrium enlarge?
Issue with mitral valve, such as mitral valve regurgitation
Which leads diagnose right atrial enlargement?
Leads II and V1
In what type of enlargement do you only see peaked P-wave, not wide P-wave?
Right atrial enlargement
Why isn’t there usually significant axis deviation in left atrial enlargement?
LA is normally electrically dominant anyways.
In limb leads, most common feature is:
Right axis deviation–shifted to 90-180*
What kind of changes occur to QRS complex in lead I in right ventricular hypertrophy?
Must be slightly more negative than positive
Which kind of hypertrophy results in increased R-wave amplitude in leads overlying left ventricle and increased S wave amplitude in leads overlying right ventricle?
Left ventricular hypertrophy
What is a pulmonary embolus?
a blockage in the pulmonary artery
Cause of PE?
A pulmonary embolism is caused by blood clots that travel to the lungs from another part of the body most commonly, the legs
PE = complication of what condition?
DVT
Old age Obesity Severe illness Stroke Spinal injury Guillian-Barré syndrome Trauma
All causes of:
Immobility, a cause of venous stasis
Cardiogenic shock Myocardial infarction Pregnancy Pelvic tumors Perioperative venous occlusion
All causes of:
Reduced flow, a cause of venous stasis
Trauma
Phelbitis
Previous DVT
All causes of:
abnormal vessels
Smoking, maligancy, pregnancy, and oral contraceptives can all affect what part of Virchow’s Triad?
Increased coaguability
A PE manifests as what kind of chest pain?
Pleuritic
Describe cough associated with PE.
Non-productive, though may be blood-tinged
What sign around the mouth and fingertips could you look for in a patient with a PE?
Cyanosis
Which pulmonic valve sound would be accentuated in a patient with a PE?
S2 (pulmonic valve)
What two lung sounds might you hear in a patient with a PE?
Pulmonary friction rub
Rales
What sign around the patient’s neck would indicate presence of a PE?
JVD
Describe patient vital signs with PE.
Dyspnea
Tachypnea (>20 breaths/min)
Tachycardia (>100 BPM)
Fever
Worst possible outcome of patient with PE would be:
CV collapse/sudden death
Medical imaging using scintigraphy and medical isotopes to evaluate the circulation of air and blood within a patient’s lungs
V/Q scan
V/Q scans are useful in determining the
V/Q ratio
What two tools are used for a V/Q scan?
Medical isotopes and scintigraphy
Sonogram of the lower extremities to evaluate for DVT
Venous ultrasonogrphy
What does a normal venous ultrasonography tell us about the possibility of a PE?
Normal venous ultrasonography doesn’t exclude PE.
Injection of radiocontrast into circulation with fluoroscopy of the lungs
Pulmonary angiography
CT slices in a helical pattern for increased resolution
Spiral CT scan
Anticoagulation treatments for PE:
Heparin
Warfarin
If a patient has PE, we will manage their airway via:
intubation and mechanical ventilation with PEEP
Mean pulmonary artery pressure >25 mmHg at rest with a PCWP, LAP, or LVEDP of <15 mmHg
Pulmonary hypertension
Three causes of pulmonary hypertension:
Pulmonary vasoconstriction
Vascular wall remodeling
Thrombosis
In pulmonary hypertension, why does RV wall stress increase?
In response to increased afterload produced by pulmonary artery hypertension
If patient presents with breathlessness, weakness, fatigue, abdominal distention, syncope, angina pectoris, or myocardial ischemia, you should suspect:
Pulmonary artery hypertension
What gallop might you hear in a patient with PAH?
S2, S3 gallop
Why should you be careful with sedatives in patients with pulmonary hypertension?
Increase PVR
Preoperatively, treat patient with PAH with:
Sildenafil or L-arginine
Inhaled NO or prostacyclin
Why should you use caution with Ketamine and Etomidate in patients with PAH?
They can cause pulmonary vasorelaxation
What kind of monitoring is recommended in patients with PAH?
central venous catheter + A-line
Name four pulmonary vasodilators?
NTG, NO, milrinone, prostacylcin
Characterized by the progressive development of airflow limitation that is not fully reversible
COPD
COPD encompasses:
chronic obstructive bronchitis + emphysema
obstruction of small airways
Chronic obstructive bronchitis
enlargement of air spaces and destruction of lung parenchyma
Emphysema
Presence of a productive cough of more than 3 months duration for more than 2 successive years indicates:
Chronic bronchitis
What is the persistent cough in chronic bronchitis due to?
Cough due to hypersecretion of mucus and not necessarily accompanied with airflow limitation
Characterized by a destructive process involving the lung parenchyma that results in loss of elastic recoil of the lungs
Emphysema
Why does emphysema increase airway resistance?
Airway collapse occurs during exhalation, leading to increased airway resistance
If you see a patient with severe dyspnea with use of accessory muscles, be suspicious of:
emphysema
Changes to lungs in chronic bronchitis
Inflammation and structural changes
Increased mucus
Changes in lungs due to emphysema
Destruction and enlargement of air spaces
Upon physical exam, your patient shows tachypnea, prolonged expiration, decreased breath sounds, and expiratory wheezes. Suspect:
COPD
Patients with COPD will have what lung sounds?
Expiratory wheezes
< FEV1/FVC ratio
COPD
< FEF25-75(forced expiratory flow between 25-75% of VC)
COPD
> RV
COPD
> FRC and TLC
COPD
What three changes might you see in chest radiography in patient with COPD?
1) Hyperlucency of lungs:arterial vascular deficiency
2) hyperinflation (flattening of diaphragms)
3) bullae
Pink puffers (emphysema) have PaO2 of:
> 65 mmHg
Blue bloaters (chronic obstructive bronchitis) have PaO2 of:
<65 mmHg
Blue bloaters (chronic obstructive bronchitis) have PaCO2 of:
<45 mmHg
Drug therapy of COPD includes:
Bronchodilators (B2 agonists)
Anticholinergics
Inhaled corticosteriods
Antibiotics
COPD treatment, surgical removal of overdistended areas allow for normal lung tissue to expand
Lung volume reduction surgery
Chronic suppurative disease of the airways of infective ideology causing destruction of airways and recurrent infections
Bronchiectasis
Mutation in chloride ion transport resulting in viscous secretions resulting in luminal airway obstruction
Cystic Fibrosis
Congenital impairment of ciliary activity in respiratory tract epithelial cells and sperm tails (chronic sinusitis, OM, productive cough & infertility)•
Primary Ciliary Dyskinesia
Narrowed airway, tightened muscles + inflamed/thickened airway all, and mucus
Asthma
Expiratory sound produced by turbulent gas flow through narrowed airways during asthma
Wheezing
10 minutes post-bronchodilator, you will see lung compliance improve by what percentage in asthmatic patients?
20%
At baseline, the flow-volume loop in asthmatic patients is
concave
Unlike in obstructive lung diseases, in RLDs what two values are preserved?
Expiratory flow rates
FEV1/FVC is preserved
In RLD, hypercarbia/arterial hypoxemia leads to vasoconstrictive pulmonary hypertension, ultimately resulting in:
Cor pulmonale
In RLD, weakness of expiratory muscle from neuromuscular disease leads to ineffective cough, ultimately resulting in:
recurring atelectasis + pneumonia
How is FEV1/FVC ratio preserved in restrictive lung disease if both FEV1 and FVC are reduced?
FVC is decreased much more so than FEV1.
Treatment of RLD
Corticosteroids, immunosuppressive agents, and cytotoxic agents
Last resort treatment of RLD=
lung transplant
Inability of the patient’s lungs to provide adequate arterial oxygenation with or without acceptable elimination of CO2
Acute respiratory failure
What is an important factor in development of acute respiratory failure?
Fatigue of the muscles of breathing
ABG in patient with ARF?
PaO2 < 60 mmHg
PaCO2 < 50 mmHg
How does ARF differ from CRF?
In ARF, pH is normal. IN CRF, pH decreases.
How do FRC and TLC change in ARF?
decreased
What develops if ARF persists?
Pulmonary hypertensionand diffuse opacification
Caused by pressure overload in which the ventricle pumps against increased resistance (afterload)
Hypertrophy
Typically caused by volume overload in which the chamber dilates to accommodate an increased amount of blood as a result of valvular insufficiency (AR & MR)
Enlargement
Hypertrophy is demonstrated in what conditions?
HTN + aortic stenosis
Enlargement is demonstrated in what conditions?
Mitral regurgitation and aortic regurgitation
What part of the EKG do we use to assess atrial enlargement?
P-waves
What part of the EKG do we use to assess ventricular hypertrophy?
QRS complex
If a chamber enlarges/hypertrophies, it can take longer for it to depolarize. How would this effect the EKG?
The wave may increase in duration.
If a chamber enlarges/hypertrophies, it can generate more current and thus a larger voltage. How would this effect the EKG?
The wave may increase in amplitude.
If a chamber enlarges/hypertrophies, a large percentage of the total electrical current can move through the expanded space. How would this effect the EKG?
The mean electrical vector (axis) would shift.
If the wave of depolarization is moving toward it, a lead will record:
a positive wave
If the wave of depolarization is moving away from it, the lead will record:
a negative wave
Depolarizations that move from negative to positive charge results in what kind of wave?
Positive
Depolarizations that move from positive to negative charge results in what kind of wave?
Negative
If Lead I and aVF are both negative, describe axis of heart.
Extreme axis deviation
If Lead I is negative and aVF is positive, describe axis of heart.
Right axis deviation
If Lead I and aVF is positive, describe axis of heart.
Normal
If Lead I is positive and aVF is negative, describe axis of heart.
Left axis deviation
The direction of the mean electrical vector, representing the average direction of current flow
Axis
The axis of the heart is only defined in what plane?
Frontal plane
Duration of normal p-wave on EKG?
<0.12 sec
The largest deflection of the isoelectric line (+ or -) should not exceed:
2.5 mm.
Which atrium depolarizes first?
Right atrium
Which leads assess right atrial enlargement?
Lead II and V1
The lead that is oriented parallel to the flow of current through the atria and therefore most positive during atrial depolarization
Lead II
The lead that is oriented perpendicular to the flow of current and therefore biphasic during atrial depolarization
Lead V1
Which portion of the P-wave increases in amplitude with right atrial enlargement?
1st portion of the p-wave
If the axis swings rightward during depolarization of the atria, what lead should you look at as parallel for conductance through atria instead of Lead II?
aVF or lead III
When can you diagnose right atrial enlargement?
When there are tall P-waves in leads II, III and aVF
Which portion of the P-wave increases in amplitude with left atrial enlargement?
2nd portion of the P-wave
In order to diagnose LAE, the p-wave should drop at least 1mm below the isoelectric line in which lead?
V1
There is a more prominent increase in duration in the p-wave when which atrium is enlarged?
LA
RAE is also known as:
P pulmonale because it is often caused by severe lung disease.
LAE is also known as:
P mitrale because mitral valve disease is the most common cause of LAE.
Most common cause of LAE?
Mitral valve disease
If RAE, p-waves will have an amplitude that exceeds _________ in which leads?
2.5 mm
In inferior leads
Which type of atrial enlargement increases P-wave duration?
LAE
Why is no significant axis deviation seen during LAE?
The LA is electrically dominant anyway–the shift only occurs when less dominant atrium takes over.
In order to diagnose right ventricular hypertrophy, the QRS complex must be slightly more negative than positive in which lead?
Lead I
In right ventricular hypertrophy, R-wave progression is disrupted:
in V1…
in V6…
In V1, the R-wave is larger than the S-wave.
In V6, the S-wave is larger than the R-wave
Increased R wave amplitude in leads overlying the left ventricle and increased S wave amplitude in leads overlying the right ventricle
Left ventricular hypertrophy
In order to be considered LVH, R wave amplitude in lead V5 or V6 plus the S wave amplitude in lead V1 or V2 exceeds:
35 mm
In order to be considered LVH, R wave amplitude in V6 exceeds R-wave amplitude in which lead?
V5
In order to be considered LVH, the R wave amplitude in lead AVL exceeds:
13 mm
Right axis deviation present, with the QRS axis exceeding +100*
RVH
