Cardiac Monitoring (Cornelius) Exam 1 Flashcards
Which of the following describes the configuration of bipolar limb leads?
A) One positive electrode and two negative electrodes
B) Two positive electrodes
C) One positive electrode and one negative electrode
D) No electrodes
C) One positive electrode and one negative electrode
Slide 3
Which of the following is a characteristic of augmented limb leads?
A) They use bipolar electrodes.
B) They use unipolar limb leads.
C) They do not require a positive electrode.
D) They measure electrical activity from the chest only.
B) They use unipolar limb leads.
Slide 4
In augmented limb leads, the lead labeled aVR corresponds to the positive electrode placed on the:
A) Left arm
B) Right arm
C) Left leg
D) Right leg
B) Right arm
Slide 4
In augmented limb leads, the lead labeled aVF corresponds to the positive electrode placed on the:
A) Left foot (leg)
B) Right arm
C) Left arm
D) Right foot (leg)
Correct Answer:
A) Left foot (leg)
Slide 4
In augmented limb leads, the lead labeled aVL corresponds to the positive electrode placed on the:
A) Right arm
B) Left arm
C) Right leg
D) Left leg
B) Left arm
Slide 4
Where is V1 placed during precordial lead placement?
A) Left fourth intercostal space at the midclavicular line
B) Right fourth intercostal space at the sternal border
C) Left fifth intercostal space at the midaxillary line
D) Right second intercostal space at the sternal border
B) Right fourth intercostal space at the sternal border
Slide 5
Where is V2 placed during precordial lead placement?
A) Left fourth intercostal space at the sternal border
B) Left fifth intercostal space at the midaxillary line
C) Right fourth intercostal space at the sternal border
D) Left fourth intercostal space at the sternal border
D) Left fourth intercostal space at the sternal border
Slide 5
Where is V3 placed during precordial lead placement?
A) Left fourth intercostal space above V5
B) Midway between V2 and V4 in the fourth rib space
C) Midway between V2 and V4 in the fifth rib space
D) Left fourth intercostal space at the midaxillary line
C) Midway between V2 and V4 in the fifth rib space
Slide 5
Where is V4 placed during precordial lead placement?
A) Left fifth intercostal space at the midclavicular line
B) Left fourth intercostal space at the sternal border
C) Right fourth intercostal space at the sternal border
D) Left fifth intercostal space at the midaxillary line
A) Left fifth intercostal space at the midclavicular line
Slide 5
Where is V6 placed during precordial lead placement?
A) Left fifth intercostal space at the midclavicular line
B) Left fifth intercostal space at the midaxillary line
C) Left fourth intercostal space at the sternal border
D) Right fourth intercostal space at the sternal border
B) Left fifth intercostal space at the midaxillary line
Slide 5
Which lead is most commonly used for continuous EKG monitoring in clinical settings?
A) Lead I
B) Lead II
C) aVR
D) V4
B) Lead II
Cornelius -V1 or V2 may be beneficial or even V5 depending on what’s going on with your patient… multi -lead monitoring will help keep an eye on all the different aspects of the heart.
Slide 6
A 12-lead EKG is useful for identifying which of the following conditions? (Select 3)
A) Cardiac damage
B) Conduction delays in the heart
C) Cardiac infections
D) Pulmonary embolism
E) Monitoring electrolyte levels
A) Cardiac damage
B) Conduction delays in the heart
C) Cardiac infections
Slide 7
Which leads are primarily used to evaluate the inferior wall of the heart?
A) Lead I, aVL
B) Lead II, Lead III, aVF
C) V1, V2
D) V5, V6
B) Lead II, Lead III, aVF
Slide 8
Which leads primarily monitor the anterior surface of the heart?
A) V1, V2
B) Lead II, Lead III, aVF
C) V3, V4
D) V5, V6
C) V3, V4
Slide 8
If you are concerned about septal wall damage, which leads would be most useful for evaluation?
A) V1, V2
B) Lead II, Lead III, aVF
C) V3, V4
D) Lead I, aVL
A) V1, V2
Slide 8
Which leads are most useful for monitoring the high lateral wall of the heart?
(Select 2)
A) V5
B) V6
C) Lead I
D) aVF
E) aVL
C) Lead I
E) aVL
V5 and V6 are lateral but not HIGH lateral
Slide 8
What is the minimum change in contiguous leads that is typically considered significant in evaluating ischemia or infarction?
A) 1 mm
B) 2 mm
C) 3 mm
D) 4 mm
B) 2 mm
Slide 8
When following the “turn signal rule” for bundle branch blocks, an upright QRS complex in V1 at the J point is indicative of which type of bundle branch block?
A) Left bundle branch block (LBBB)
B) Right bundle branch block (RBBB)
C) Left posterior fascicular block
D) Nonspecific intraventricular conduction delay
B) Right bundle branch block (RBBB)
Slide 9
When following the “turn signal rule” for bundle branch blocks, a downward QRS complex in V1 at the J point is indicative of which type of bundle branch block?
A) Left bundle branch block (LBBB)
B) Right bundle branch block (RBBB)
C) Left posterior fascicular block
D) Nonspecific intraventricular conduction delay
A) Left bundle branch block (LBBB)
Slide 10
Which of the following EKG characteristics is indicative of right atrial hypertrophy (RAH)?
A) Notched P wave in lead V1
B) Initial component of the P wave larger in V1
C) M-shaped P wave in lead II
D) Inverted T wave in limb leads
B) Initial component of the P wave larger in V1
Slide 11
A P wave height greater than how many millimeters in any limb lead suggests right atrial hypertrophy (RAH)?
A) 1.5 mm
B) 2.0 mm
C) 2.5 mm
D) 3.0 mm
C) 2.5 mm
slide 11
Which component of the P wave in lead V1 is larger in left atrial hypertrophy LAH?
A) Initial component
B) Terminal component
C) Entire P wave
D) QRS complex
B) Terminal component of diphasic P in V1 larger
Slide 12
P-waves for lead II and Lead VI are shown below. What would be indicated by this EKG waveform?
A) Notched P wave in lead V1
B) Right atrial hypertrophy
C) M-shaped P wave in lead II
D) Bi-atrial enlargement
Bi-atrial enlargement
Slide12
Right ventricular hypertrophy (RVH) is characterized by smaller R waves and more depolarization toward which lead?
A) V6
B) Lead II
C) V1
D) aVR
C) V1
Cornelius - *Be mindful of your QRS changes for V1, especially if you have RVH, and when we start worrying about patients with concentric hypertrophy, *
Slide 13
Which precordial lead shows a large R wave that is indicative of left ventricular hypertrophy?
A) V1
B) V3
C) V5
D) V6
C) V5
Slide 14
Which of the following EKG characteristics is indicative of left ventricular hypertrophy (LVH)?
A) Small R wave in V5
B) Large S wave in V1
C) Small S wave in V1
D) R wave progression through V1-V3
B) Large S wave in V1
Slide 14
What is the combined depth of the S wave in V1 and the height of the R wave in V5 used to diagnose LVH?
A) 25 mm
B) 30 mm
C) 35 mm
D) 40 mm
C) 35 mm
Slide 14
Which of the following EKG findings is most indicative of myocardial ischemia?
A) Elevated ST segment
B) Inverted, symmetrical T wave
C) Deep Q waves
D) Peaked T waves
B) Inverted, symmetrical T wave
Starts with reduced supply of O2 from the coronary arteries
Slide 15
What EKG finding is most indicative of an acute myocardial “acute injury”?
A) Inverted T waves
B) ST segment elevation
C) Deep Q waves
D) Widened QRS complex
B) ST segment elevation
Slide 16
Which EKG finding is most indicative of a past myocardial infarction (Transmural)?
A) ST segment elevation
B) Inverted T waves
C) Deep, significant Q waves
D) Shortened PR interval
C) Deep, significant Q waves
Slide 17
For a Q wave to be considered significant and indicate an old infarction, it must be at least how wide?
A) 0.5 mm
B) 1 mm
C) 2 mm
D) 1.5 mm
B) 1 mm
Slide 17
What other criteria, in addition to being at least 1 mm wide, must be met for a Q wave to signify an old infarction?
A) Must be at least 1/3 the height of the QRS complex
B) Must be present in all precordial leads
C) Must be present in only one lead
D) Must be present only in limb leads
A) Must be at least 1/3 the height of the QRS complex
and 2 related leads
slide 17
What is the primary indication for the use of an artificial cardiac pacemaker?
A) Treatment of ventricular fibrillation
B) Correction of disturbances
C) Management of hypertrophic cardiomyopathy
D) Prevention of atrial fibrillation
B) Correction of disturbances in cardiac impulse conduction
Elderly….SSS
Anti-bradycardic treatment
Slide 19
Which of the following are components of an artificial cardiac pacemaker? (Select 2)
A) Pulse generator
B) Electrode leads
C) Defibrillator paddles
D) Electrode generator
A) Pulse generator
B) Electrode leads
Slide 19
Which of the following is not an example of an artificial cardiac pacemaker?
A) Transthoracic pacemaker
B) Transvenous pacemaker
C) Transverse pacemaker
D) Transcutaneous pacemaker
C) Transverse pacemaker
Slide 19
What is the primary function of the generator in a pacemaker system?
A) To detect heart rate
B) To transmit electrical impulses
C) To provide energy and electrical circuits
D) To monitor pacemaker battery life
C) To provide energy and electrical circuits
Slide 20
Which part of the pacemaker is the insulated wire that connects the generator to the heart?
A) Electrode
B) Lead
C) Pulse generator
D) Grounding wire
B) Lead
Slide 20
Which part of the pacemaker that comes into contact with the actual heart?
A) Electrode
B) Lead
C) Pulse generator
D) Grounding wire
A) Electrode
Cornelius - that’s where the energy is actually gonna be exposed to the heart itself, the lead goes down to the electrode from the generator and then the electrodes actually contacts the heart.
Slide 20
What is the difference between unipolar and bipolar electrodes in pacemaker systems?
A) Bipolar electrodes provide lower sensitivity to electromagnetic interference (EMI)
B) Unipolar electrodes are used for temporary pacing, and bipolar electrodes are permanent
C) Bipolar electrodes use the heart as a ground, while unipolar does not
D) Unipolar electrodes use more energy, and bipolar electrodes use less energy
D) Unipolar electrodes use more energy, and bipolar electrodes use less energy
Unipolar electrodes - neg electrode in chamber; positive electrode (grounding)
More sensitive to Electromagnetic interference (EMI)
Bipolar electrodes - both electrodes in chamber being paced
Slide 20
True or False
Bipolar electrodes are the most common pacemaker
True
Slide 20
Which of the following best describes a multipolar pacemaker system?
A) A system with multiple generators in one device
B) A system with one lead and multiple electrodes in different chambers
C) A pacemaker that uses external grounding for pacing
D) A pacemaker system designed for short-term use only
B) A system with one lead and multiple electrodes in different chambers
Cornelius - *You may also see that you use multiple electrodes. So for instance sometimes we’ll see leads that will go across the septum. So you may have like biatrial electrodes or you may have biventricular electrodes. *
Slide 20
What does Roman numeral I in the pacemaker code represent?
A) Chamber(s) paced
B) Chamber(s) sensed
C) Response to sensing
D) Rate modulation
A) Chamber(s) paced
Cornelius - you may have an atrial pacemaker, you may have a ventricular pacemaker, or you may have dual AV pacemakers, or you may have no pacers, not programmed at all.
Slide 21
What does Roman numeral II in the pacemaker code represent?
A) Multisite pacing
B) Chamber(s) sensed
C) Chamber(s) paced
D) Response to sensing
B) Chamber(s) sensed
Cornelius - *instead of it being a non -demand device, it’s actually on demand…it pays attention to see what the patient’s heart rate is, and then it determines its response.
Especially with ventricular pacemakers, where it’s just set for a default rate at a round number like 60, 70, or 80. So, if you’re looking at somebody and you see that they’ve got a big, wide QRS and it’s kind of that clock regular rate of like 60, 70, or 80, be very suspicious that they may have a pacemaker, even if you don’t see pacer spikes.
*
Slide 21
What does Roman numeral III in the pacemaker code represent?
A) Chamber(s) paced
B) Multisite pacing
C) Response to sensing
D) Rate modulation
C) Response to sensing
Cornelius - *What this means is that everything can be programmed differently depending on the device.
I - Inhibit - Sometimes there’s nothing done differently when it senses. If you have an inhibit, the pacemaker senses that there’s a traditional or a spontaneous depolarization, it will not activate, so the pacemaker doesn’t do anything.
T - Trigger - You may have a patient that falls outside of the set parameters, maybe they become bradycardic, so then the device will trigger.
D - Dual - You may have dual, which means it’s capable of doing both. The dual is the most common that you’re going to see as far as like response to sensing
Slide 21
What does Roman numeral IV in the pacemaker code represent?
A) Rate modulation
B) Chamber(s) paced
C) Multisite pacing
D) Chamber(s) sensed
A) Rate modulation
Cornelius - Rate modulation may mean that it is able to adapt a little bit.
That’s not very common. Usually, if you see that, it’s more in response to like overdrive pacing.
Slide 21
What does Roman numeral V in the pacemaker code represent?
A) Chamber(s) sensed
B) Response to sensing
C) Multisite pacing
D) Rate modulation
C) Multisite pacing
Cornelius - The last one is if you have multiple locations where it’s able to pace. So is it like by atrial, by ventricular, or is it both atria and ventricular
Slide 21
What happens when a pacemaker is inhibited?
A) The pacemaker discharges if intrinsic activity is sensed.
B) The pacemaker discharges regardless of intrinsic activity.
C) The pacemaker does not discharge if intrinsic activity is sensed.
D) The pacemaker paces at a default rate.
C) The pacemaker does not discharge if intrinsic activity is sensed.
Slide 22
Which setting allows a pacemaker to discharge only during testing of the device?
A) Inhibited
B) Triggered
C) Rate modulation
D) Multisite pacing
B) Triggered
Cornelius - They may be inhibiting/triggering to demonstrate that it’s able to pace. They use medications to alter the heart rate.
You may also see that they will increase the patient’s heart rate just to prove that they can do it and they have good capture
Slide 22
What factors can influence rate modulation in a pacemaker?
(Select all that apply-4)
A) Motion
B) Intrinsic atrial depolarization
C) Vibration
D) Heart rate only
E) Minute ventilation
F) Right ventricular pressure
G) Left ventricular pressure
A) Motion
C) Vibration
E) Minute ventilation
F) Right ventricular pressure
Cornelius - modulation is like an artifact setting, they may be able to use that to determine the patient’s heart rate actually hasn’t increased and its just artifact. You can separate out the real QRS complexes from the artifact. You may see that there’s some modulation settings in there where they’re able to kind of tailor that for the patient.
Slide 22
Which condition is multisite pacing most commonly used for?
A) Atrial fibrillation
B) Cardiomyopathies
C) Bradycardia
D) AV block
B) Cardiomyopathies
Cornelius - The biggest thing we’re seeing with as far as multisite pacing is gonna be ventricular pacers for people with like horrible dilated cardiomyopathies.
You will occasionally see it for AFib, but Bi -V is the most common one that we do see.
Slide 22
What type of pacemaker is represented by an atrial impulse followed by a ventricular pacer spike and QRS complex? (B in the picture)
A) Atrial sequential pacemaker
B) Ventricular pacemaker
C) Atrioventricular sequential pacemaker
D) Dual chamber pacemaker
Correct Answer: B) Ventricular pacemaker
Cornelius - the atria is still working normally on its own, but the ventricles aren’t working. So you see that pacer spike and then the big QRS complex that follows it.
Slide 23
Which pacemaker type generates both atrial and ventricular spikes followed by corresponding depolarizations? (C in the picture)
A) Single chamber pacemaker
B) Ventricular sequential pacemaker
C) Atrioventricular sequential pacemaker
D) Atrial sequential pacemaker
C) Atrioventricular (AV) sequential pacemaker
Cornelius - there’s an atrial spike and then the atrial impulse is the atria depolarized. And then you have a ventricular spike and then a ventricular depolarization.
Slide 23
Which of the following are important considerations for perioperative care of patients with pacemakers? (Select 3)
A) Turn off the pacemaker during surgery
B) Ensure the grounding pad is placed distant from the pacemaker
C) Interrogate the pacemaker pre- and post-operatively
D) Turn the filter off on the cardiac monitor
E) Use monopolar electrocautery near the pacemaker
F) Place a magnet on the patients chest over the heart
B) Ensure the grounding pad is placed distant from the pacemaker
C) Interrogate the pacemaker pre- and post-operatively - NOT routinely done anymore or required
D) Turn the filter off on the cardiac monitor - there’s usually a pacer setting on the cardiac monitor…be familiar with whatever the kind of functionality of your monitor is. Some do it automatically. Some you have to do it manually
Slide 24
True or False
Monopolor Cautery is safe to use with patients with cardiac pacemakers
FALSE
Bipolar Cautery is safer to use with cardiac pacemakers
Cornelius - you want to try and avoid putting the grounding pad anywhere near it. You also want to try and avoid using monopolar electroconrading anywhere near the device if possible
Slide 24
What might happen if you place a magnet on an older pacemaker device?
A) It will deactivate the pacemaker
B) It will change the pacemaker to a non-demand mode
C) It will increase the heart rate to 100 bpm
D) It will trigger defibrillation
B) It will change the pacemaker to a non-demand mode
Cornelius - Historically putting a magnet on a device would put it into a non -demand mode So it would just go to a regular rate of 60 70 or 80 depending on what the backup programming was for.** Some newer devices don’t do that**, so just be very cautious
Slide 24
What chambers are paced with a BiV pacemaker?
A) Right atrium and both ventricles
B) Left atrium and both ventricles
C) Both atria only
D) Both ventricles only
A) Right atrium and both ventricles *(trans-septal) *
C - *one lead that goes into the right atrium and then you’ll have a lead that goes into each ventricle…it goes through the septum *
Slide 25
What is the purpose of BiV pacing in pacemakers?
A) Increase heart rate
B) Improve RV-LV activation time
C) Reduce atrial fibrillation
D) Provide electrical shocks during arrhythmias
B) Improve RV-LV activation time
C - to increase the patient’s cardiac resynchronization (CRT), so the right and left ventricle are working and increasing EF % and improving CO.
Historically these people have bad cardiomyopathy and as a result of that the impulses are delayed as they transmit. They’re pretty dependent on pacemakers…somebody that can’t go without having their pacemaker on. Putting then in non -demand mode is probably fine for them because they’re gonna default to something that’s adequate, but be very cautious about turning these devices off or manipulating them
Slide 25
Which of the following methods is NOT used to provide anesthesia for pacemaker placement?
A) Cervical plexus block
B) Sedation
C) Topical
D) Local infiltration
E) Periclavicular block
F) General Anesthesia
C) Topical
C- You can put the patient under general anesthesia… but a lot of times, because they’re so sick, we do sedation and a local. Sometimes we’ll a periclavicular block. Sometimes we’ll do like a cervical plexus block .It really just depends on where they’re putting the device in the surgeon may just infiltrate with local
Slide 25
What is the typical ejection fraction (EF) threshold that may qualify a patient for Bi-V pacing?
A) 40-50%
B) 30-35%
C) 50-60%
D) 20-25%
B) 30-35% - “Moderate/Severe”
C- 30% to 35%, you’ll see is younger athletes that we see that are having out of hospital cardiac arrest with disease early on
Slide 26
Which of the following is a requirement for Bi-V pacing?
(Select 2)
A) Normal heart function
B) EF of 36-40%
C) Intraventricular conduction delays
D) History of cardiomopathy induced cardiac arrest
C) Intraventricular conduction delays
D) History of cardiomopathy induced cardiac arrest
Slide 26
What type of pacing does a magnet induce in a pacemaker?
A) Asynchronous pacing with rate modulation
B) Synchronous pacing with no rate modulation
C) Asynchronous pacing with no rate modulation
D) Continuous synchronous pacing
C) Asynchronous pacing with no rate modulation
DOO vs VOO
DOO
Dual paced, with no sensing or inhibition. DOO is used for asynchronous pacing in both the atria and ventricles. It’s often used when a magnet is placed over a pacemaker or when a patient is having surgery. (per google)
VOO
Ventricular paced, with no sensing or inhibition. VOO is used for asynchronous pacing in the ventricle.
Slide 27
What might occur when a magnet is placed over a pacemaker?
A) It always switches to asynchronous pacing
B) It always increases the pacing rate
C) It may cause no change in pacing
D) It always decreases the pacing rate
C) It may cause no change in pacing
C - So you may put that small donut magnet over the top of the patient’s pacemaker and nothing happens
Slide 27
After a magnet detects battery depletion, follow-up is typically intensified to every ______.
A) 1 week
B) 2 weeks
C) 4 weeks
D) 3 months
C) 4 weeks
Magnet possibly detects decreases pulse amplitude or width…Inadequate capture
Slide 27
What is the recommended type of cautery to use during surgery for a patient with an AICD/Bi-V device?
A) Monopolar
B) Bipolar
C) Laser
D) None of the above
B) Bipolar
Slide 27
After surgery, a patient with an AICD/Bi-V device will likely require ________ of the device.
A) Reprogramming
B) Removal
C) Interrogation
D) Testing
C) Interrogation
Slide 27
Which of the following are recommended practices for perioperative care of a patient with an battery powered AICD/Bi-V device? Select 2
A) Optimize patient condition
B) Turn filter ON on cardiac monitor
C) Use monopolar cautery
D) Ensure back-up pacing ability
E) Intaoperative interrogation of the device
A) Optimize patient condition
D) Ensure back-up pacing ability
- Postoperative interrogation of the device*
Slide 27
What is the primary function of an implantable cardioverter-defibrillator (ICD)?
Select 3
A) To assist with heart rate pacing
B) To terminate ventricular fibrillation
C) To defib Supraventricular Tachycardia
D) To monitor atrial fibrillation
E) To terminate ventricular tachycardia
B) To terminate ventricular fibrillation
C) To defib Supraventricular Tachycardia - 10% inappropriate
E) To terminate ventricular tachycardia
Corny - *they’re designed for vFib or VTAC, but you’ll see sometimes the patients will go into SVT and it may have a wide enough complex to meet the pre -programmed specifications for the device, and they’ll wind up defibrillating SVT.
*
Slide 27
Which of the following are criteria ICDs measure when evaluating arrhythmias?
Select 3
A) P-R intervals
B) Onset abrupt or gradual
C) QRS width (normal or wide)
D) Rate of atrial fibrillation
E) Consistency of R-R intervals
B) Onset abrupt or gradual
C) QRS width normal or wide
E) Consistency of R-R intervals or variable
Cornelius - *ICD usually looks at the kind of width of the QRS complex because it is primarily targeting ventricular rhythms, so it’s going to be a wide QRS.
*You may run into trouble if you’ve got kind of an irregular heart rate because it’s looking for that R -to -R interval, so if you’ve had an irregular R -to -R interval, it may not be able to calculate the heart rate appropriately. *
Or maybe you have a whole lot of beats that are close together, and you have a period of tachycardia, but it’s not sustained.
Slide 27
The most common location for inserting a central venous pressure (CVP) line is the ___________, with the catheter positioned at the junction of the vena cava and the right atrium.
A) Left Subclavian Vein
B) Right Internal Jugular Vein
C) Femoral Vein
D) Left External Jugular Vein
B) Right Internal Jugular Vein
Slide 32
Which of the following factors significantly influence CVP measurement? Select 3
A) Blood volume
B) Vascular tone
C) Left ventricular ejection fraction
D) Oxygen saturation
E) Respiratory effort
A) Blood volume,
B) Vascular tone,
E) Respiratory effort
Cornelius - *if you have somebody that’s being ventilated by positive pressure ventilation, you may have an artificial increase in the CVP because the intrathoracic pressure is increasing. *
*Whereas if they’re breathing spontaneously, since they have that vacuum of the diaphragm dropping down, it doesn’t tend to alter it quite the same way. *
Slide 32
What is central venous pressure (CVP) primarily used to assess?
A) Left heart function and cardiac output
B) Blood volume and right heart function
C) Pulmonary artery pressure
D) Systemic vascular resistance
B) Blood volume and right heart function
Slide 32
True or False
A snapshot of the CVP measurements is a very accurate at calculating of blood volume and RIGHT heart function
FALSE
Cornelius - the big thing you need to take away is that a snapshot with the CVP is not very helpful. It’s more of a trending device.
If I start seeing my CVP increasing, things that could cause it –> fluid overload, pericardial effusions.
If I see my CVP dropping over a long period of time –> I may be volume depleted. But they’re not very good is like one little snapshot.
Slide 32
The normal range for CVP in a patient with spontaneous breathing is ________ mmHg.
A) 1-7
B) 7-12
C) 12-16
D) 4-10
A) 1-7
Slide 32
Which of the following is NOT an indication for a CVP line?
A) Temporary hemodialysis
B) Pulmonary artery catheter placement
C) Blood pressure monitoring
D) Rapid infusion of fluids/blood
C) Blood pressure monitoring
Slide 33
Which of the following are valid indications for the placement of a CVP line? Select 4
A) Caustic drug administration
B) Aspiration of air emboli
C) Repeated blood testing
D) Monitoring left heart function
E) Transvenous cardiac pacing
F) Increased coagulopathy
A) Caustic drug administration
B) Aspiration of air emboli
C) Repeated blood testing
E) Transvenous cardiac pacing
Slide 33
Label the a, c, & v waveforms on the Wiggers diagram below.
Schmidt PTSD…
The “A wave” on a CVP waveform is a result of:
A) Ventricular contraction
B) Atrial contraction
C) Tricuspid valve closure
D) Blood filling the right atrium
B) Atrial contraction
C- you have the atrial depolarization and then you have increased atrial pressure. And this is really the atrial that’s starting to fill from that preload.
So the atrial starts to dilate, dilate, dilate, and then you have that A wave that appears.
Slide 34
Which of the following are characteristics of the “A wave” in a CVP waveform? select 3
A) Occurs after the “P” wave
B) Represents ventricular contraction
C) Increases atrial pressure
D) Provides the “atrial kick”
E) Occurs after the “QRS” complex
A) Occurs after the “P” wave
C) Increases atrial pressure
D) Provides the “atrial kick”
Slide 34
The “C wave” on a CVP waveform is associated with:
A) Atrial contraction
B) Isovolumetric contraction of the ventricle
C) Tricuspid valve opening
D) Rapid ventricular filling
B) Isovolumetric contraction of the ventricle
- Backward “bowing” of the valves (from ventricular contraction) slightly displacing blood backwards.
Slide 34
Which of the following are true about the “C wave” in the CVP waveform? Select 3
A) It follows the “R” wave on the ECG
B) Tricuspid valve closed and ventricle bulges toward the atria
C) It represents the tricuspid valve opening and atria bulges out
D) It interrupts the decreasing atrial pressure
E) It is seen after the “P” wave on the ECG
A) It follows the “R” wave on the ECG
B) Tricuspid valve closed and ventricle bulges toward the atria
D) It interrupts the decreasing atrial pressure
slide 35
The “X descent” on the CVP waveform represents:
A) Atrial contraction
B) Isovolumetric relaxation of the ventricle
C) A decrease in atrial pressure during ventricular systole
D) Tricuspid valve opening
C) A decrease in atrial pressure during ventricular systole
Slide 36
The “X descent” on the CVP waveform is sometimes referred to as ______.
A) Increase in atrial pressure
B) Systolic collapse
C) Diastolic collapse
D) Ventricular diastole
B) Systolic collapse
Steep drop in pressure as atria relax and start filling.
Slide 36
The “V wave” on the CVP waveform represents:
A) Atrial contraction
B) Venous filling of the atrium
C) Tricuspid valve opening
D) Isovolumetric contraction of the ventricle
B) Venous filling of the atrium
Slide 37
Which of the following are true about the “V wave” on the CVP waveform? Select 3
A) It is associated with atrial contraction
B) The tricuspid valve remains closed during the V wave
C) It follows the “T” wave on the ECG
D) It occurs during late systole
E) It represents the opening of the tricuspid valve
B) The tricuspid valve remains closed during the V wave
C) It follows the “T” wave on the ECG
D) It occurs during late systole
Slide 37
The “Y descent” on the CVP waveform occurs when the ______ valve opens, allowing initial blood flow into the ______.
A) Mitral; left ventricle
B) Tricuspid; right atrium
C) Tricuspid; right ventricle
D) Mitral; left atrium
C) Tricuspid; right ventricle
Slide 38
Which of the following are true about the “Y descent” on the CVP waveform? Select 2
A) It occurs when the mitral valve opens
B) It is called diastolic collapse
C) It represents blood flow into the right atrium
D) It follows the “T” wave on the ECG
E) It represents the initial blood flow into the right ventricle
F) It is called the systolic collapse
B) It is called diastolic collapse,
E) It represents the initial blood flow into the right ventricle
Slide 38
In atrial fibrillation, what happens to the CVP waveform?
A) There is a tall “a” wave
B) The “c” wave is absent
C) The “a” wave is absent
D) The “v” wave is smaller
C) The “a” wave is absent
Cornelius -* If you have somebody that’s got AFib because you don’t have kind of that consistent atrial filling, you may not have an A wave. *
Likewise you may have a larger C wave because there’s more volume in there when it finally contracts
Slide 39
In tricuspid regurgitation, the ___________ is absent because the tricuspid valve is ___________.
A) Y; stenotic
B) X; incompetent
C) A; absent
D) V; open
B) X descent ; incompetent
Slide 39
Which of the following are characteristics of tricuspid stenosis on the CVP waveform? Select 2
A) Tall “a” wave
B) Absent “a” wave
C) No “x” descent
D) Changes in the “y” descent
E) Larger “c” wave
A) Tall “a” wave
D) Changes in the “y” descent
Cornelius - *somebody with tricuspid stenosis, you may have a really large A wave because of that back pressure and the inability of it to effectively contract. *
You may also not see the Y descent happen there just because it’s masked by other waveforms, usually that big A wave
Slide 39
KRISTA’s START!!!
What is 1 on the photo?
Distal Port
Most distal - Monitors PAP
Cornelius: very distal port that’s coming out beyond that balloon, and that’s what you’re gonna use to monitor your pulmonary artery pressure.
Slide 40-41
What is 2 on the photo?
30 cm proximal
Monitors CVP
Slide 40-41
What is the preferred site for PA catheter placement in most patients?
A) Left Subclavian
B) Right Internal Jugular
C) Left Internal Jugular
D) Right Subclavian
B) Right Internal Jugular
Slide 42
What 3A and 3B on the photo?
3A = 40 cm mark
thin lines = 10 cm
3B = 50 cm mark
thick line = 50 cm
Slide 40-41
Where is the PA catheter at based on the waveform below?
Right Atrium
Slide 42
What is 4 on the photo?
4th Lumen
Houses temperature thermistor
Lies just proximal to balloon
Slide 40-41
Where is the PA catheter at based on the waveform below?
RV
Slide 42
What is 5 on the photo?
CVP port
Slide 40-41
Where is the PA catheter at based on the waveform below?
Pulmonary Artery
Slide 42
What is 6 on the photo?
Lock for Balloon
3rd lumen leads to a balloon near the tip
Slide 40-41
Where is the PA catheter at based on the waveform below?
Wedged
Slide 42
What is 7 on the photo?
Balloon Syringe
Most of these are gonna be 1/2 to 1 1/2 C’s of air that go into that balloon
Slide 40-41
The PA catheter typically used in clinical practice is how many centimeters long?
A) 80 cm
B) 100 cm
C) 110 cm
D) 130 cm
C) 110 cm
marked at 10 cm intervals
Cornelius: You may also see there’s some variation as far as the size of the catheters for length, so some of them are longer than 110 centimeters, some are shorter, especially if you have one that’s more of like a pacing catheter or something like that.
Slide 43
What PA catheter complication is associated with very high mortality?
A) Endocarditis
B) Catheter knots
C) Pulmonary artery rupture
D) Dysrhythmias
C) Pulmonary artery rupture
- Hemoptysis (Bright red and copious)
- Hypotension
Slide 44
Which of the following characteristics might be observed on a CVP waveform in a patient with mitral regurgitation? Select 3
A) Tall V-wave
B) Prominent A-wave
C) C & V wave fused
D) No X-descent
A) Tall V-wave
C) C & V wave fused
D) No X-descent
No specificity/sensitivity to severity of MR d/t: LA compliance, LA volume
Slide 48
Which of the following features might be observed on a CVP waveform in a patient with mitral stenosis?
A) Tall V-wave
B) Prominent A-wave
C) Slurred, early Y-descent
D) Absent C-wave
C) Slurred, early Y-descent
A wave may be absent d/t frequent assoc. with A-fib
Slide 49
Which of the following is considered the gold standard for cardiac output measurement?
A) Bolus Thermodilution
B) Doppler Ultrasound
C) Fick Principle
D) Impedance Cardiography
A) Bolus Thermodilution
Slide 55
Which of the following characteristics are typically observed in the PA catheter waveform of a patient with an acute LV myocardial infarction?
A) Tall A-waves
B) Decreased LVEDP
C) Increased LVEDV
D) Flattened V-waves
E) Increased LVEDP
A) Tall A-waves
C) Increased LVEDV
E) Increased LVEDP
PAWP increases
Slide 50
Which of the following statements about the bolus thermodilution method are correct? (Select 3)
A) It involves injecting cold saline into the pulmonary artery.
B) Cardiac output is directly proportional to the degree of temperature change.
C) Measurements are taken in the pulmonary artery using a thermistor.
D) Three attempts are averaged to obtain the final measurement.
A) It involves injecting 10mL cold saline into the pulmonary artery.
C) Measurements are taken in the pulmonary artery using a thermistor.
D) Three attempts are averaged to obtain the final measurement.
CO inversely proportionate to degree of change
Slide 55
What is the typical range for Systemic Vascular Resistance (SVR)?
A) 400 - 800 dynes/sec/cm⁵
B) 800 - 1600 dynes/sec/cm⁵
C) 1000 - 2000 dynes/sec/cm⁵
D) 1200 - 1800 dynes/sec/cm⁵
B) 800 - 1600 dynes/sec/cm⁵
Slide 54
At what depth (in cm) should the PAC tip be located when it reaches the right atrium?
A) 10-15 cm
B) 20-25 cm
C) 30-35 cm
D) 40-45 cm
B) 20-25 cm
Slide 43
What is the typical range for Pulmonary Vascular Resistance (PVR)?
A) 20 - 100 dynes/sec/cm⁵
B) 40 - 180 dynes/sec/cm⁵
C) 60 - 200 dynes/sec/cm⁵
D) 100 - 300 dynes/sec/cm⁵
B) 40 - 180 dynes/sec/cm⁵
Slide 54
Which of the following factors contribute to inaccuracies in thermodilution measurements? (Select 4)
A) Mishandling of the injectate
B) Intracardiac shunts
C) Fluctuations in patient temperature
D) Rapid infusion of warm fluids
E) Tricuspid/pulmonic regurgitation
A) Mishandling of the injectate
B) Intracardiac shunts
C) Fluctuations in patient temperature
E) Tricuspid/pulmonic regurgitation
Rapid fluid infusion of cold fluids
Slide 57
What is the typical depth range (in cm) for the PAC to reach the right ventricle?
A) 10-15 cm
B) 20-25 cm
C) 30-35 cm
D) 40-45 cm
C) 30-35 cm
Slide 43
Which of the following statements are true about continuous cardiac output monitoring? (Select 4)
A) It is more accurate during positive pressure ventilation.
B) Data is averaged over 3-6 minutes.
C) It involves injecting cold saline for temperature measurement.
D) It provides better reproducibility than bolus thermodilution.
E) It delays updates in unstable patients compared to thermodilution.
A) It is more accurate during positive pressure ventilation.
B) Data is averaged over 3-6 minutes. Updated q 30-60 seconds
D) It provides better reproducibility than bolus thermodilution.
E) It delays updates in unstable patients compared to thermodilution.
Small quantities of heat are released from filament in RV
Slide 58
What is the typical range for stroke volume in a healthy adult?
A) 40 - 60 mL
B) 50 - 80 mL
C) 60 - 90 mL
D) 70 - 100 mL
C) 60 - 90 mL
Slide 54
Pulse contour devices use the area under the curve (AUC) of arterial pressure tracings to estimate which of the following? Select 2
A) Central venous pressure (CVP)
B) Cardiac output (CO)
C) Stroke volume variation (SVV)
D) PA pressure
B) Cardiac output (CO)
C) Stroke volume variation (SVV)
and pulse pressure
Slide 59
At what depth (in cm) should the PAC tip be located when it reaches the pulmonary artery?
A) 20-25 cm
B) 30-35 cm
C) 40-45 cm
D) 50-55 cm
C) 40-45 cm
Slide 43
What is the typical range for mixed venous O₂ saturation (SvO₂) in a healthy adult?
A) 50 - 60%
B) 60 - 70%
C) 70 - 80%
D) 80 - 90%
C) 70 - 80%
Slide 54
True or False
Pulse contour devices rely on an algorithm that measures from end diastole to end systole to calculate ventricular compliance.
True
+/- 0.5 L/min compared to thermodilution
Slide 59
The wedge position of the PAC is typically found at what depth (in cm)?
A) 20-25 cm
B) 30-35 cm
C) 40-45 cm
D) 45-55 cm
D) 45-55 cm
Slide 43
Which of the following factors are likely to cause inaccuracies in pulse contour measurements? (Select 3)
A) Atrial fibrillation
B) Bradycardia
C) Site of arterial puncture
D) Vasopressors affecting arterial trace
E) Diuretic use
A) Atrial fibrillation
C) Site of arterial puncture
D) Vasopressors affecting arterial trace
and requires frequent re-calibration
Slide 60
What would the following cardiac output thermodilution curve indicate?
Low CO
(Longer time to return to baseline)
Slide 56
Echocardiography uses which type of waves to produce images?
A) Radio waves
B) High-frequency ultrasound waves
C) Microwaves
D) Infrared waves
B) High-frequency ultrasound waves
Density x velocity (sound through tissue)
Slide 61
Which of the following is/are NOT potential complication(s) associated with a pulmonary artery catheter (PAC)?
A) Dysrhythmias, PVCs/V-tach
B) Transient RBBB or complete heart block
C) Catheter knots
D) Pulmonary edema
E) Pulmonary infarction
F) Pulmonary artery rupture
G) Endocarditis
H) Valve injury
D) Pulmonary edema
Slide 44
Which of the following statements are true about echocardiography? (Select 3)
A) It uses low-frequency ultrasound waves.
B) M-mode can measure tissue planes such as ventricular wall mass.
C) Doppler mode shows real-time cardiac motion.
D) 2-D mode is used to shows function and real-time motion.
E) Doppler can determine the speed and direction of blood flow
B) M-mode can measure tissue planes such as ventricular wall mass.
D) 2-D mode is used to shows function and real-time motion.
E) Doppler can determine the speed and direction of blood flow.
Slide 61
What would a high cardiac output thermodilution curve look like?
Small curve/area
Slide 56
What SVV percentage indicates that a patient with hypotension is likely to respond well to fluid resuscitation when using a pulse contour device?
A) SVV < 5%
B) SVV > 10%
C) SVV = 8%
D) SVV = 3%
B) SVV > 10%
Slide 59
In the FoCUS method, where is the parasternal window placed?
A) At the PMI
B) 3-5 intercostal space (ICS)
C) Below the xiphoid process
D) In the subclavian region
B) 3-5 intercostal space (ICS)
Slide 63
Which of the following is considered a comprehensive exam using the FoCUS method?
A) 5 views
B) 10 views
C) 15 views
D) 28 views
D) 28 views
Anterior structures closest to transducer…..at the top of image
Slide 63
Where is the apical window positioned during a FoCUS examination?
A) Below the xiphoid
B) At the 3-5 ICS
C) At the point of maximal impulse (PMI)
D) At the left clavicle
C) At the point of maximal impulse (PMI)
Slide 63
Which of the following pressures are monitored by a Pulmonary Artery Catheter (PAC)? Select 2
A) Pulmonary Artery Pressure (PAP)
B) Central Venous Pressure (CVP)
C) Pulmonary Artery Wedge Pressure (PAWP)
D) Right Atrial Pressure (RAP)
A) Pulmonary Artery Pressure (PAP)
C) Pulmonary Artery Wedge Pressure (PAWP)
* Indirect measurement of left atrial pressure
* PAD pressure often used as alternative
Slide 46
The subcostal window in the FoCUS method is found:
A) Just below the xiphoid process
B) At the mid-clavicular line
C) At the left sternal border
D) In the 2nd intercostal space
A) Just below the xiphoid process
Slide 63
Which of the following are part of the standard five views in a focused transthoracic echocardiogram (TTE)? (Select all that apply)
A) Parasternal Long Axis
B) Parasternal Short Axis
C) Apical Four Chamber
D) Subcostal Four Chamber
E) Subcostal IVC
ALL OF THE ABOVE
Slide 63
For accurate measurement, the tip of the Pulmonary Artery Catheter (PAC) should be in which zone of the lung?
A) Zone 1
B) Zone 2
C) Zone 3
D) Any zone is acceptable
C) Zone 3
Schmidty!
Slide 46
Which of the following is primarily assessed using the parasternal long-axis view in a focused TTE? Select 2
A) Overall Function
B) Pulmonary artery
C) Left heart and aortic root
D) Inferior vena cava
A) Overall Function
C) Left heart (Left ventricle, left atrium) and aortic root
Slide 64
Which conditions can cause a Pulmonary Artery Catheter (PAC) to provide a poor estimate of Left Ventricular End-Diastolic Pressure (LVEDP)? (Select 5)
A) Compliance
B) Aortic regurgitation
C) PEEP
D) Ventricular Septal Defect (VSD)
E) Mitral stenosis/regurgitation
F) Systemic hypertension
A) Compliance
B) Aortic regurgitation
C) PEEP
D) Ventricular Septal Defect (VSD)
E) Mitral stenosis/regurgitation
Cornelius: It doesn’t provide a good estimate of Compliance. If you have somebody with Aortic regurgigation, it’s gonna artificially increase your numbers. PEEP may affect things because you’re increasing pressure on the heart. If you’ve got a VSD in place, you may have altered flow so it may not provide you with a good estimate, or if you have somebody with a any sort of Mitral problem, you may not get good numbers.
Slide 47
The parasternal short-axis view in a TTE is primarily used to assess which of the following?
A) Right atrium and tricuspid valve
B) Pulmonary valve and left atrium
C) Left ventricular function and volume status
D) Inferior vena cava and aortic root
C) Left ventricular function and volume status
Slide 64
The apical four-chamber view is primarily used to assess ________ vs ________ size and the function of the ________ and ________ valves.
A) Right atrium (RA); Left atrium (LA); aortic; mitral
B) Right ventricle (RV); Left ventricle (LV); tricuspid; mitral
C) Left ventricle (LV); Right ventricle (RV); aortic; pulmonary
D) Right ventricle (RV); Left ventricle (LV); aortic; tricuspid
B) Right ventricle (RV); Left ventricle (LV); tricuspid; mitral
Slide 64
“The subcostal four chamber view is primarily used to assess ________ and the ____ heart chambers”?
A) Right ventricular hypertrophy; two
B) Pericardial effusion; four
C) Aortic stenosis; three
D) Mitral valve function; two
B) Pericardial effusion; four heart chambers
Pericardial effusion often next
to right heart
Slide 65
The subcostal IVC view is primarily used to assess the ___ and ___ of the inferior vena cava (IVC), especially during spontaneous respiration. Select 2
A) Diameter
B) Collapsibility
C) Wall motion abnormalities
D) Pulmonary valve function
A) Diameter
B) Collapsibility
Slide 65
Which of the following conditions can mixed venous oximetry help assess? (Select 2)
A) Shock
B) Hyperglycemia
C) Cardiac output
D) Liver function
A) Shock
C) Cardiac output
Cornelius: this is kind of falling out of favor…it’s not quite as popular as it was. The mixed venous oximetry is kind of an indirect indicator of cardiac output. The problem we run into and the reason we don’t use it is often is because many times all those factors (Hgb, Arterial saturations, O2 consumption) are changing at the same time.
Slide 51-52
Which of the following are the two main contraindications to intraoperative TEE?
A) Aortic stenosis and esophageal varices
B) Esophageal varices and laparoscopic banding
C) Mitral valve prolapse and esophageal stricture
D) Pulmonary hypertension and left atrial enlargement
B) Esophageal varices and laparoscopic banding
Slide 66
What is the correct formula for calculating cardiac output?
A) CO = HR / SV
B) CO = SV x HR
C) CO = SV + HR
D) CO = HR - SV
B) CO = SV x HR
Total blood flow generated by heart/minute
Slide 53
What is the typical range for cardiac output in a healthy adult?
A) 2.5 - 4.0 L/min
B) 4.0 - 6.5 L/min
C) 5.0 - 7.5 L/min
D) 6.5 - 9.0 L/min
B) 4.0 - 6.5 L/min
Slide 54
Intraoperative TEE serves as a ___ , ___ , and ___ tool during surgical procedures.
A) monitor; rescue; research
B) diagnostic; preventative; decision-making
C) monitor; decision-making; rescue
D) therapeutic; diagnostic; monitor
C) monitor; decision-making; rescue
and assessment of valvular function
Slide 66
