Cardiac monitoring and cardiac drugs Flashcards by Kevin Dale

Indications for 5-lead EKG

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

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What single lead is best to monitor the LV?

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

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

Lead II and V5

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Subendocardial ischemia results in:

ST segment depression

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transmural myocardial ischemia is detected as:

ST segment elevation

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Coronary perfusion occurs when in the RV?

Systole and diastole

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Coronary perfusion occurs when in the LV?

Diastole only

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Mechanically the_________ is subjected to higher pressures than the_______

endocardium

epicardium

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Arterial catheter indications:

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

Level of Right atrium

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

MAP

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Dicrotic notch=

closure of aortic valve

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

arterial systolic pressure

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

arterial sBP

stroke volume (SV)

pulse pressure

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Overdamped:

falsely underestimates systolic BP and overestimates diastolic BP

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Underdamped:

falsely overestimates systolic BP and underestimates diastolic BP

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

1-2

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

> 2

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

< 1.5

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Factors for over dampened arterial waveform

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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Factors for under dampened arterial waveform

Catheter whip or artifact

Stiff non-compliant tubing

Hypothermia

Tachycardia or dysrhythmia

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Contraindications for a CVC

(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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What is the most common access route for CVC placement?

Internal Jugular (right)

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What are the locations you can put a CVC?

The IJ veins,

subclavian (SC) veins,

femoral veins

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Blood flowing away from an ultrasound transducer is

BLUE

Blood flowing toward an ultrasound transducer is

RED

Disadvantage of using the subclavian vein for CVC placement?

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

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

the thoracic duct may be lacerated

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

The left subclavian approach

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

10cm

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

15cm

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

20cm

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

40cm

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

40cm

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

50cm

Tip of CVP catheter should be placed just above what?

junction of vena cava and RA

Tip of PA catheter should be placed where?

pulmonary artery

Distance from right IJ to Junction of vena cava and RA

15cm

Distance from right IJ to right atrium

15-25cm

Distance from right IJ to right ventricle

25-35cm

Distance from right IJ to pulmonary artery

35-45cm

Distance from right IJ to pulmonary artery wedge position

40-50cm

Complications while floating a PA/Swan

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)

What does the central venous pressure (CVP) measure

right atrial pressure

What does the CVP act as a predictor of?

Pt preload and volume status

Normal CVP range

1-10

what is CVP a good indicator of?

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

A wave

Right atrial contraction just after P wave (atrial depolarization)

C wave

Right ventricular contraction Just after QRS (ventricular depolarization) (in line w S) closure of the tricuspid valve

X descent

Right atrial relaxation ST segment

X descent

Right atrial relaxation ST segment

V wave

passive filling RA Just after T wave begins ( ventricular repolarization) (coincides with part of RV systole)

Y descent

RA empties through open TV After T wave

Loss of a waves/only v waves:

Atrial fibrillation Ventricular pacing in the setting of asystole A wave occurs when synchronized contraction of RA is lost

Giant/ “cannon” a waves:

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)

Large V waves:

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 tricuspid valve during RV systole. This increases pressure and volume in the right atria = large V wave (C +V waves may blend together)

High CVP value:

RV failure Tricuspid stenosis OR regurgitation Cardiac tamponade Constrictive pericarditis Pericarditis Volume overload Pulmonary HTN PEEP Transducer below phlebostatic axis

Low CVP value

Hypovolemia ARDS Transducer above phlebostatic axis

CVP should be zeroed at the:

phlebostatic axis (4th intercostal space mid anteroposterior level)

CVP should be measured at

end expiration

PAC normal systolic value

Systolic: 20-30 mmHg

PAC normal diastolic value

8-12 mmHg

where should the tip of the PAC be?

Zone 3 = continuous blood flow -Provides most accurate estimate of LVEDP

Causes of high PA pressures

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

Causes of low PA pressures

Hypovolemia May see with RV failure May see with tricuspid regurgitation or stenosis

What is the pulmonary artery wedge pressure or PAOP measuring?

left ventricular end-diastolic pressure (LVEDP)

Why is a PAOP not commonly monitored?

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

Normal PAOP value

8-12 mmHg Or 5-15

what else can you use to estimate a wedge pressure?

PAD

what else can you use to estimate a wedge pressure?

PAD

Causes of a high wedge pressure

LV failure Mitral stenosis or regurgitation Cardiac tamponade Constrictive pericarditis Volume overload ischemia

Causes of a low wedge pressure

Hypovolemia RV failure Tricuspid regurgitation or stenosis Pulmonary embolism

normal CO

5-6 L/m

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

The area under the curve is _______ proportional to cardiac output

INVERSELY

Overestimates of CO using thermodilution

Low injectate volume Injectate that is too warm Thrombus on the thermistor of the PA catheter Partially wedged PA catheter

Underestimates of CO using thermodilution

Excessive injectate volume Injectate solutions that are too cold

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

SVC IVC coronary sinus 3 samples mix in pulmonary artery

Normal SVO2

mal SVO2 = 65-75%

SVO2 decrease caused by increased O2 consumption:

Stress Pain Thyroid storm Shivering Fever Seizure

SVO2 decrease caused by decrease o2 delivery

↓ Pao2 ↓ HBG ↓ C.O.

SVO2 increased d/t decreased o2 consumption

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

SVO2 increased d/t increased o2 delivery

↑ Pao2 ↑ HBG ↑ C.O.

Indications for TEE

-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

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

approx. 35-40 cm from teeth

Posterior structures are displayed at_____ and anterior structures ______of the screen

top of screen at the bottom

Best single view for routine monitoring SWMA

Short axis at midpapillary level

TEE is the gold standard for assessing what?

myocardial function

What does SOAP stand for?

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

other monitors:

cerebral oximetry BIS monitor TEE Istat

normal CO

5-6 L/m

Factors for under dampened arterial waveform

Catheter whip or artifact Stiff non-compliant tubing Hypothermia Tachycardia or dysrhythmia