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CV- principles > Cardiac monitoring and cardiac drugs > Flashcards

Cardiac monitoring and cardiac drugs Flashcards

1
Q

Indications for 5-lead EKG

A

-Diagnosis of dysrhythmias
-Diagnosis of ischemia
-Diagnosis of electrolyte disturbances
-Monitor effect of cardioplegia during aortic cross-clamp

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2
Q

What single lead is best to monitor the LV?

A

V5
Positioned along the anterior axillary line in the fifth intercostal space

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3
Q

90% of ischemic episodes will be detected by ECG if which 2 leads are viewed?

A

Lead II and V5

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4
Q

Subendocardial ischemia results in:

A

ST segment depression

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5
Q

transmural myocardial ischemia is detected as:

A

ST segment elevation

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6
Q

Coronary perfusion occurs when in the RV?

A

Systole and diastole

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7
Q

Coronary perfusion occurs when in the LV?

A

Diastole only

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8
Q

Mechanically the_________ is subjected to higher pressures than the_______

A

endocardium

epicardium

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9
Q

Arterial catheter indications:

A

-CT/CV surgery
-Major vascular
-Neurosurgery
-trauma
-Major abdominal
-solid organ transplant
-acid-base/electrolyte monitoring
-Dysrhythmias
-Marked obesity
-CPB
-LVAD

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10
Q

BP is measured at the level of the transducer which is where?

A

Level of Right atrium

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11
Q

On the arterial wave form, what does the area under the curve represent?

A

MAP

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12
Q

Dicrotic notch=

A

closure of aortic valve

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13
Q

Hypovolemia is suggested by a decrease in _____ ______ ____ with positive-pressure ventilation (pulsus paradoxus).

A

arterial systolic pressure

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14
Q

Respiratory variation of what 3 things can be used as goal-directed parameters to identify patients who will respond to fluid administration

A

arterial sBP

stroke volume (SV)

pulse pressure

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15
Q

Overdamped:

A

falsely underestimates systolic BP and overestimates diastolic BP

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16
Q

Underdamped:

A

falsely overestimates systolic BP and underestimates diastolic BP

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17
Q

How many oscillations during a square wave test will an optimally damped aline produce?

A

1-2

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18
Q

How many oscillations during a square wave test will a underdamped aline produce?

A

> 2

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19
Q

How many oscillations during a square wave test will an overdamped aline produce?

A

< 1.5

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20
Q

Factors for over dampened arterial waveform

A

Air within a catheter or transducer causes most pressure monitoring errors.

-Friction in the fluid pathway

-Bubbles in the tubing

-Clots in the tubing

-Vasospasm

-Long, narrow tubing (i.e. extensions added)

-Compliant tubing
make sure that pressure tubing is used if extension is required (do not use IV extension tubing)

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21
Q

Factors for under dampened arterial waveform

A

Catheter whip or artifact

Stiff non-compliant tubing

Hypothermia

Tachycardia or dysrhythmia

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21
Q

Factors for under dampened arterial waveform

A

Catheter whip or artifact

Stiff non-compliant tubing

Hypothermia

Tachycardia or dysrhythmia

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22
Q

Contraindications for a CVC

A

(a)Presence of significant carotid disease

(b)Recent cannulation of the IJ (with the concomitant risk of thrombosis)

(c)Contralateral diaphragmatic dysfunction

(d)Thyromegaly or prior neck surgery

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23
Q

What is the most common access route for CVC placement?

A

Internal Jugular (right)

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24
Q

What are the locations you can put a CVC?

A

The IJ veins,

subclavian (SC) veins,

femoral veins

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25
Q

Blood flowing away from an ultrasound transducer is

A

BLUE

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26
Q

Blood flowing toward an ultrasound transducer is

A

RED

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27
Q

Disadvantage of using the subclavian vein for CVC placement?

A

Subclavian vein cannulation carries the highest rate of pneumothorax of any approach.

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28
Q

What is a risk of left sided subclavian vein CVC placement?

A

the thoracic duct may be lacerated

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29
Q

What approach is recommended as the first option for a PAC placement?

A

Right IJ

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30
Q

Distance to the junction of the vena cava and RA from subclavian

A

10cm

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31
Q

Distance to the junction of the vena cava and RA from Right IJ

A

15cm

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32
Q

Distance to the junction of the vena cava and RA from Left IJ

A

20cm

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33
Q

Distance to the junction of the vena cava and RA from femoral vein

A

40cm

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34
Q

Distance to the junction of the vena cava and RA from right median basilic vein

A

40cm

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35
Q

Distance to the junction of the vena cava and RA from left median basilic vein

A

50cm

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36
Q

Tip of CVP catheter should be placed just above what?

A

junction of vena cava and RA

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37
Q

Tip of PA catheter should be placed where?

A

pulmonary artery

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38
Q

Distance from right IJ to Junction of vena cava and RA

A

15cm

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39
Q

Distance from right IJ to right atrium

A

15-25cm

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40
Q

Distance from right IJ to right ventricle

A

25-35cm

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41
Q

Distance from right IJ to pulmonary artery

A

35-45cm

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42
Q

Distance from right IJ to pulmonary artery wedge position

A

40-50cm

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43
Q

Complications while floating a PA/Swan

A

Dysrhythmias while obtaining access

Floating PA catheter:
-Pulmonary artery rupture
-Dysthymias
-RBBB –>complete HB (DO NOT float a PAC into a patient with LBBB, advancing to RV can cause RBBB leading to complete HB)

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44
Q

What does the central venous pressure (CVP) measure

A

right atrial pressure

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45
Q

What does the CVP act as a predictor of?

A

Pt preload and volume status

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46
Q

Normal CVP range

A

1-10

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47
Q

what is CVP a good indicator of?

A
  1. Intravascular volume
  2. Venous tone
  3. RV compliance
    ** not a good indicator of fluid status
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48
Q

A wave

A

Right atrial contraction

just after P wave (atrial depolarization)

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49
Q

C wave

A

Right ventricular contraction

Just after QRS (ventricular depolarization) (in line w S)

closure of the tricuspid valve

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50
Q

X descent

A

Right atrial relaxation

ST segment

51
Q

X descent

A

Right atrial relaxation

ST segment

52
Q

V wave

A

passive filling RA

Just after T wave begins ( ventricular repolarization)

(coincides with part of RV systole)

53
Q

Y descent

A

RA empties through open TV

After T wave

54
Q

Loss of a waves/only v waves:

A

Atrial fibrillation

Ventricular pacing in the setting ofasystole

A wave occurs when synchronized contraction of RA is lost

55
Q

Giant/ “cannon” a waves:

A

Junctional rhythms

Complete AV block

PVCs

Ventricular pacing

Tricuspid or mitral stenosis

Diastolic dysfunction

Myocardial ischemia

Ventricular hypertrophy

atria contracts and empties against a high resistance (either @ valve or noncompliant ventricle)

56
Q

Large V waves:

A

Tricuspid regurgitation

Acute increase in

intravascular volume

RV papillary muscle ischemia

tricuspid regurg allow a portion of the RV volume to pass through a closed but incompetent tricuspidvalve during RV systole. This increases pressure and volume in the right atria = large V wave (C +V waves may blend together)

57
Q

High CVP value:

A

RV failure

Tricuspid stenosis OR regurgitation

Cardiac tamponade

Constrictive pericarditis

Pericarditis

Volume overload

Pulmonary HTN

PEEP

Transducer below phlebostatic axis

58
Q

Low CVP value

A

Hypovolemia

ARDS

Transducer above phlebostatic axis

59
Q

CVP should be zeroed at the:

A

phlebostatic axis (4th intercostal space mid anteroposterior level)

60
Q

CVP should be measured at

A

end expiration

61
Q

PAC normal systolic value

A

Systolic: 20-30 mmHg

62
Q

PAC normal diastolic value

63
Q

where should the tip of the PAC be?

A

Zone 3 = continuous blood flow

-Provides most accurate estimate of LVEDP

64
Q

Causes of high PA pressures

A

LV failure

Mitral stenosis or regurgitation

L-R shunt

ASD or VSD

Volume overload

Pulmonary HTN

Catheter “whip” catheter may be coiled or advanced too far

65
Q

Causes of low PA pressures

A

Hypovolemia

May see with RV failure

May see with tricuspid regurgitation or stenosis

66
Q

What is the pulmonary artery wedge pressure or PAOP measuring?

A

left ventricular end-diastolic pressure (LVEDP)

67
Q

Why is a PAOP not commonly monitored?

A

due to increased risk of vessel rupture when wedging is performed incorrectly/catheter is not in the ideal position

68
Q

Normal PAOP value

A

8-12 mmHg

Or 5-15

69
Q

what else can you use to estimate a wedge pressure?

70
Q

what else can you use to estimate a wedge pressure?

71
Q

Causes of a high wedge pressure

A

LV failure

Mitral stenosis or regurgitation

Cardiac tamponade

Constrictive pericarditis

Volume overload
ischemia

72
Q

Causes of a low wedge pressure

A

Hypovolemia

RV failure

Tricuspid regurgitation or
stenosis

Pulmonary embolism

73
Q

normal CO

73
Q

normal CO

74
Q

How many injections should you do for accuracy of CO measurement via thermodilution method?

75
Q

The area under the curve is _______ proportional to cardiac output

76
Q

Overestimates of CO using thermodilution

A

Low injectate volume

Injectate that is too warm

Thrombus on the thermistor of the PA catheter

Partially wedged PA catheter

77
Q

Underestimates of CO using thermodilution

A

Excessive injectate volume

Injectate solutions that are too cold

78
Q

Where do you need blood returning from to measure a SVO2 (mixed venous oxygen saturation)

A

SVC
IVC
coronary sinus

3 samples mix in pulmonary artery

79
Q

Normal SVO2

A

mal SVO2 = 65-75%

80
Q

SVO2 decrease caused by increased O2 consumption:

A

Stress
Pain
Thyroid storm
Shivering
Fever
Seizure

81
Q

SVO2 decrease caused by decrease o2 delivery

A

↓ Pao2
↓ HBG
↓ C.O.

82
Q

SVO2 increased d/t decreased o2 consumption

A

Hypothermia
Cyanide toxicity-(SNP, sepsis,
left to right shunt)

83
Q

SVO2 increased d/t increased o2 delivery

A

↑ Pao2
↑ HBG
↑ C.O.

84
Q

Indications for TEE

A

-Identify systolic wall motion abnormalities (SWMA) and vascular aneurysms

-calculation of EF

-ventricular preload

-measurement of blood flow within the heart and across the valves

85
Q

TEE probe is placed in the esophagus to a depth of?

A

approx. 35-40 cm from teeth

86
Q

Posterior structures are displayed at_____ and anterior structures ______of the screen

A

top of screen

at the bottom

87
Q

Best single view for routine monitoring SWMA

A

Short axis at midpapillary level

88
Q

TEE is the gold standard for assessing what?

A

myocardial function

89
Q

What does SOAP stand for?

A

Suction, oxygen (and other gases), airway equipment, pharmacy

90
Q

other monitors:

A

cerebral oximetry
BIS monitor
TEE
Istat

91
Q

Pts with HTN will display an exaggerated response to:

A

induction agents (more HoTN) and laryngoscopy (more extreme HTN)

92
Q

Administering _______ or _______can decrease the hyperdynamic sympathetic response to laryngoscopy

A

beta blockers

arterial dilators (nitro)

93
Q

Why would you use lidocaine IV prior to intubation?

A

Blunt laryngeal reflex with intubation

94
Q

Predictors of hypotension during induction:

A

are age >50
ASA 3-4
baseline MAP <70
coadmin of high doses of fentanyl

95
Q

metabolism for etomidate

A

ester hydrolysis

96
Q

What does etomidate act as to increase the BP?

A

Alpha 2B adrenoceptor agonist

97
Q

what does etomidate inhibit?

A

11b hydroxylase–> leads to adrenocortical suppression bc it’s essential in the body’s production of corticosteroids and mineralcorticoids

98
Q

The effects of a single etomidate dose can last for how many hours?

99
Q

etomidate can cause increases in morbidity and mortality in patients who are:

A

on prior corticosteroid therapy and/or patients in a septic state

100
Q

When is etomidate contraindicated?

A

Known sensitivity
Adrenal suppression
acute porphyrias

101
Q

What is acute intermittent porphyria?

A

metabolic disorder caused by deficiencies in the enzymes that produce heme (building block of hemoglobin)

102
Q

Most common symptoms of acute intermittent porphyria?

A

abdominal pain
N/V

103
Q

MOA of ketamine:

A

noncompetitive NMDA antagonist

inhibits glutamate;

depressant effect on thalamic nuclei —> this blocks afferent signals of pain perception to the thalamus and cortex

104
Q

MOA of ketamine:

A

noncompetitive NMDA antagonist

inhibits glutamate;

depressant effect on thalamic nuclei —> this blocks afferent signals of pain perception to the thalamus and cortex

105
Q

What does ketamine inhibit?

A

tumor necrosis factor alpha:

may be responsible for its anti-inflammatory and antihyperanalgesic effects

106
Q

what is the active metabolite of ketamine? What is it’s active percentage?

A

Norketamine (20-30%)

107
Q

what kind of waves does ketamine cause on EEG?

108
Q

How can you combat the increasing effect ketamine has on on CBF, CMRO2 and ICP?

A

administer GABA agonist

109
Q

Primary effects of Precedex are

A

sedation
analgesia
anxiolysis
reduced post-op shivering and agitation
CV sympatholytic actions

110
Q

What will happen if you bolus dexmedetomidine too fast?

A

HTN and tachycardia

111
Q

*Mu effects

A

Respiratory depression
bradycardia
sedation
euphoria
miosis (pupillary constriction)
urinary retention
N/V
pruritus

112
Q

*Delta effects

A

Respiratory depression
urinary retention
pruritus

113
Q

Kappa effects

A

Possible respiratory depression
sedation
dysphoria (state of unease)
hallucinations
delirium
miosis
diuresis
anti-shivering

114
Q

complications of vasopressin

A

GI ischemia
decreased cardiac output
digital necrosis
cardiac arrest at elevated doses

115
Q

*Which med causes increased coronary artery perfusion due to increase in diastolic BP

A

norepinephrine

116
Q

Which med is typically a first line pressor when needed in a cardiac case?

A

Norepinephrine

117
Q

MOA for dobutamine

A

*Primarily a beta 1 agonist with some B2 effects

118
Q

what is the indication for dobutamine

A

increase CO/CI esp when coming off pump

119
Q

Milrinone MOA

A

*phosphodiesterase 3 inhibitor;

prevent the breakdown of cAMP

120
Q

What does milrinone decrease?

A

preload AND afterload

121
Q

What does Hemoptysis while floating a swan indicate?

A

PA RUPTURE

122
Q

insertion site with the highest risk of injuring thoracic duct

A

Left IJ

(can happen w left subclavian)

123
Q

what is the risk of inserting a swan in the subclavian?

A

pneumothroax

124
Q

why is LBBB a contraindication for PA catheter

A

RBBB= complete heart block

125
Q

CVP should be measured at:

A

4th ICS mid anteroposterior level (phlebostatic axis)

CV- principles (8 decks)

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