Cardio/Pulm Flashcards
Normal BP:
Pre-HTN BP:
Stage 1 HTN:
Stage 2 HTN:
Normal BP: 120/80
Pre-HTN BP: 120-139/80-89
Stage 1 HTN: 140-159/90-99
Stage 2 HTN: >/= 160 / >/= 100
Primary HTN no known cause
Secondary HTN usually due to renal
95th percentile children for HTN
TV: 10% IRV: 50% ERV: 15% RV: 25% VC: 75% (IRV+TV+ERV) IC: 60% (TV+IRV) FRC: 40% (ERV+RV) TLC: 100%
.
ABI = systolic blood pressure at ankle and arm for PAD.
Use Brachial artery and post tib artery.
= Higher ankle systolic / Higher brachial systolic
Values:
> /= 1.30 rigid artery, need US to test for PAD
- 0 - 1.3 normal, NO BLOCKAGE
- 8 - 0.99 mild blockage, intermittent claudiation p ! during ex
- 4-0.79 moderate, p! during ex
Cardiac conduction pathway:
SA node - normal pace maker of heart.... AV node... Bachaan Bundle (RA to LA)... Bundle of His... ////IV SEPTUM//// R and L bundle branches.... Purlinje fibers... ventricular walls
Normal ABG Values: PH PaCO2 PaO2 HCO3 SaO2
PH: 7.35 - 7.45 PaCO2: 35-45 mmHg PaO2: 80-100 mmHg HCO3: 22-26 mEq/L SaO2: 95-98% Eucapnia: normal level of Co2 in arterial blood mild Hypoxemia: Pa02 60-79 mmHg Mod: 40-59 Severe:
Premature atrial contraction (PAC):
impulse before SA node (p wave immature, abnormal config). Can progress to atrial flutter, atrial tachy
Atrial flutter:
250-350 BPM, atrial tachy
saw-tooth p waves
A-fib:
350-600 BPM
.
Borg Dyspnea Scale:
Borg Dyspnea scale: 0 = no breathlessness 0.5 = very, very slight 1 = very slight 2 = slight 3 = moderate 4 = somewhat severe 5= severe breathlessness 6 = 7 = very severe 8 9 = very, very severe 10 = max breathlessness
Heart sounds
S1 (lub) close mitral and tricuspid, beginning of systole (decreased in 1st degree heart block)
S2: (dub) close aortic and pulmonary, end of systole (decreased in aortic stenosis )
S3 (vibration of distended ventricle walls) due to passive blood flow from atria into ventricles during rapid filling of diastole phase *normal in children, abnormal in adults b/c associated with CHF (“ventricular gallop”)
S4 (ventricular vibration c ventricular filling and atrial contraction), pathological; associated with HTN, MI, stenosis, MI (“atrial gallop”)
Phases of BP sounds:
Phase 1 - clear tap, appearance of pulse systolic
Phase 2 - soft and louder
3 - crisper and louder
4 - muffled and softer
5 - disapears completely (last beat is diastolic)
**Deflate BP cuff 2-3 mmHg/second
BP in children:
Age 3-17, BP is by percentiles %
SBP and DBP = 90-95%
stage 1: SBP and/or DBP >/= 95 - = 99% plus 5mmhg
stage 2: > 99th % plus 5 mmhg SBP and/or DBP
1st deg AV block:
PR > 0.2 second
constant beat to beat, NO symptoms
2nd deg AV block
AV conduction between atria & ventricles fail intermittently
2 types:
a) Mobitz type 1 (Wenckebach block) - progressive prolongation of PR until impulse not conducted, benign
b) Mobitz type 2 - MORE serious, dec in CO due to consecutive/normal PRs followed by nonconduction of
>/= 1 impulses; can progress to 3rd deg AV block
3rd deg AV block
ALL impulses blocked @ AV node
none transmitted to ventricles
atrial rate > ventricular rate
***requires pacemaker, EMERGENCY
Premature ventricular complex (PVC):
P wave absent, QRS wide/weird shape
Bigeminy, normal sinus rhythm followed by PVC
Trigeminy, PVC occurs after every 2 normal sinus impulses
V-tach: >/= 3 PVCs consecutively with ventricular rate of > 150 BPM; leads to cardiac arrest
EKG abnormalities:
ST dep, ST elev, T-wave inversion
ST depression - subendocardial ischemia, or digitalis toxcity or hypokalemia
ST elevation - EARLIEST sign of acute MI
T-wave inversion - occurs hours or days after MI due to delay in repolarization
Homans sign:
Passively DF ankle with Knee STRAIGHT, positive produces pain in calf or popliteal space
Absolute indications to stop cardiac exercise test:
Decrease in SBP >/= 10mmHg
moderate angina (3 out of 4 on angina scale)
Increase of nervous system sxs (dizziness, ataxia etc)
Signs of poor perfusion (pallor, cyanosis)
Sustained v-tach
1.0 mm ST elevation (without Q waves)
Relative indications to stop cardiac exercise test:
Decrease in SBP > 10 mmHg > 2mm ST depression Arrhythmia, bundle branch block Fatigue, SOB, claudication, increase in chest pain HTN response (>250 SBP and/or > 115 DBP)
Normal HR values:
normal infant: 100 - 130 BPM
normal child: 80 - 100 BPM
normal adult: 60-100 BPM
*stop activity if SpO2 drops below 85% in COPD or 88% in critically ill
Grading of pulses, and FEV1/FVC
Grading of pulses: 0 = absent pulse 1 = small, reduced pulse 2+ normal 3+ large, bounding
FEV1 / FVC 80% (normal) BUT if decrease in FVC then demonstrates restrictive lung disease (due to dec lung volumes)
Hematology: RBCs: WBCs: Platelets: PTT: Hematocrit:
Hematology:
RBCs:
4.3 - 10.6 M ; 4.0 - 5.2 F
WBCs: 3.54 - 9.06
neutro: 0.4-0.70
lympho: 0.20 - 0.50
mono: 0.04-0.08
eosino: 0.00-0.06
baso: 0.00 - 0.02
Platelets: 165 - 415
PTT: 26.3 - 39.4 sec
Hematocrit: 0.388 - 0.464 M , 0.354 - 0.444 FMore lab values: Hb: Total cholsterol: LDL: HDL: Triglycerides:
More lab values: Hb: 13.3 - 16.2 M ; 12.0 - 15.8 F Total cholsterol: 240 high) LDL: 160-189 high) HDL: 60 high Triglycerides: >200-499 high
claudication test:
2.0 mph treadmill, 0-12% incline grade.
initial claudication distance = pain free distance
absolute = max distance, terminated due to pain
grade 1 = initial discomfort
grade 2 = moderate discomfort, can divert attention away
grade 3 = severe, cannot distract from pain
grade 4 = excruciating, unbearable
alpha adrenergic antagonist:
ace inhibitor:
A2 receptor antagonist:
alpha adrenergic antagonist: decreases peripheral vascular tone by blocking Alpha 1 adrenergic receptors
(causes vasodilation, dec BP)
(for HTN, BPH)
ace inhibitor:for HTN, CHF
(decreases BP and preload by suppressing A1 to A2 enzyme conversion)
A2 receptor antagonist: block alpha2 receptors by limiting vasoconstriction and stimulation of vascular tissue
Antiarryhthmic drugs:
class 1: sodium channel blocker, controls cardiac excitation and conduction.
class 2: beta blocker, inhibits symptathetics by blocking beta adrenergic receptors
class 3: potassium and sodium channel blocker, prolongs repolarization, MOST effective
class 4: calcium channel blocker, depress depolarization, decrease conduction through AV node
Lymphedema, cardiac tamponade:
Lymphedema: 2 types
a. primary - rare, inherited due to lymph vessel problem
b. secondary - condition/procedure damaged lymph vessel
* achiness, fibrous, heaviness, brawny, fullness, NONPITTING EDEMA
Cardiac tamponade: fluid in pericardium puts pressure on heart (prevents heart from filling properly), less blood leaves heart (decreases BP, can be fatal)
rheumatic fever, acute respiratory distress syndrome, atelectasis:
rheumatic fever:from group A steptococcocus due to poorly treated strep throat. can damage heart valves and cause HF
Acute respiratory distress syndrome (ARDS): sudden respiratory failure secondary to fluid accumulation in alevoli, fatal 25-40%
Atelectasis: area of lung does not inflate properly or collapses. Caused by factors that prevent deep breathing (post-op pain etc)
bronchiectasis, chronic bronchitis, COPD:
bronchiectasis: progressive, OBSTRUCTIVE, abnormal dilation of bronchus. irreversible, chronic infection weakens bronchial walls (dilate bronchi and bronchioles)
- seen in cystic fibrosis
chronic bronchitis: productive cough for 3 Month over 2 consecutive years
COPD (chronic bronchitis, emphysema):
- block airflow due to narrowing of bronchial tree
- alevolar destruction, air trapping (increases TLC and RV)
types of breathing:
biot’s: irregular depth and rate vary with periods of apnea (due to increased ICP, damage to medulla)
bradypnea: 20)
cheyna-stokes (periodic): decreasing rate and depth of breathing with periods of apnea (CNS damage)
eupnea - normal rate and depth
(hyperpnea - increased rate/depth, hypopnea - decreased rate/depth)
Kussmaul’s - deep and fast breathing (metabolic acidosis)
paradoxical - chest wall moves in with inhalation and out with exhalation (opposite of normal. chest truama, paralysis of diaphragm)
FEV, VE, PEF:
FEV: forced expiratory volume. amount of air exhaled in specified amount of time.
VE: minute volume ventilation. Volume of air expired in one minute (VE = TV x RR)
PEF: Peak expiratory flow. Max flow of air during forced expiration.
3 types of cardiomyopathy:
- dilated cardiomyopathy: require ace inhibitors, beta blockers, digoxin, diuretics, pacemaker.
- hypertrophic cardiomyopathy: meds decrease HR, stabilize rhythm, lopressor and calcium channel blockers
- restrictive cardiomyopathy: improve sxs, use diuretics, anti HTN, and anti-arryhtmia meds
Anticoagulants, antithrombotics, beta blockers:
anticoagulants: for post surgery. Ex: heparin, comoudain (warfarin).
Antithrombotics: inhibit platelet aggregation and clot formation, for post - MI. Ex: bayer (aspirin), plavix
Beta blockers: decrease myocardial O2 demand (decreases HR and Heart contractility) by blocking beta adrenergic receptors For HTN, angina, arryhtmia, HF. -olols med names. “*WATCH FOR OTHO HYPOTENSION side effect
Ca channel blockers, diuretics:
calcium channel blockers: decrease entry of Ca into smooth muscle which leads to decreased myocardial contraction, dec’d O2 demand of heart, and inc’d vasodilation. For HTN, angina, CHF, arryhtmia.
Diuretics: increase excretion of sodium and water (urine) which leads to decreased plasma volume, decreased preload, and ultimately dec’d BP. For CHF, edema, HTN, pulmonary edema.
nitrates, positive inotropic agents:
nitrates: decrease ischemia via smooth muscle relaxation and dilation of peripheral vessels (for angina)
positive inotropic agent: increase force and velocity of myocardial contraction to decrease HR, decrease conduction velocity of AV node, decrease degree and activation of sympathetics. (For HF, atrial fib) ex: lanoxin (digoxin)
thrombolytics:
breaks up clot (via plasminogen -> plasmin), plasmin breaks down clots and allow occluded vessels to maintain bloodflow. For: MI, PE, ischhemic stroke.
ex: activase
types of airways:
nasopharyngeal: nasotracheal suctioning
oral pharyngeal: maintains airway
endotracheal: for mech ventilation
traceostomy: prolonged mech vent
heart sympathetics versus paraympathetics
heart sympathetics: achieved with release of epinephrine and norepinephrine. Chambers beat faster (chronotropic effect) and with greater force of contractility (inotropic effect).
Heart Parasympathetics: via ACh from vagusn erve, slows heart rate (chronotropic) via ACh release from vagus nerve on SA node
absent breath sounds = pneumothorax, lung collapse.
words faint in normal lung, if hear voice sounds this indicates consolidation (atelectasis, fibrosis )
..
BMI:
Kg/ meters squared.
/= 40.0 extrmee obese
- in children, 85-95th percentile at risk
> 95th percentile overweight or obese
capillary refill time
2 sec abnormal, compromised capillary blood flow
empyema - infected fluid which turns into abscess.
Hypoxemia - decd level of O2 in arterial blood
Hypoxia - decd level of O2 in TISSUE despite adequate perfusion of tissue
*creatine phosphokinase (Ck-Mb) appears in blood 4 hours after MI, peaks after 12-24 h and decreases over 48-72 hours
,
CPR
100 compressions.min. 30 compressions to 2 breaths, 1 breath every 6-8 seconds (1 second breath)
Pursed lip breathing, forward lean:
pursed lip breathing: decreases RR and decreaes dyspnea, maintains positive airway pressure to prevent airway collapse (emphysema)
Fwd lean with UE support: inc length tension relationship of diaphragm, allows pecs to assist
Inpatient cardiac rehab (PHASE 1):
D.C if HR > 130 or >30 BPM above RHR, 2nd-3rd deg AV block, DBP >/= 110, dec in SBP > 10, significant ventricular/atrial dysarythmias, ST depression (ischemia),
active ex begins 24h after bypass graft surgery or 2 days after MI.
Intensity must be
immediate outpatient cardiac rehab (PHASE 2)
can last up to 12 weeks. cease activity if experience rating 1 on angina scale (go to hospital if not relieved by cessation of activity and 3 sublingual nitro tabs (one every 5min))
D/C if SBP drops with increased work, or > 250SBP or > 115 DBP, ST depression of >1mm, 2nd-3rd deg AV block, ventricular dysaryhtmia, Angina
Ribs: true false floating
Ribs 1-7 True
Ribs 8-10 false
Ribs 11-12 floating
R lung = 3 lobes.
L lung = 2 lobes (plus lingula )
Inspiration - diapgragm, ex/interal intercostals
*accessory muscles SCM , scalenes, pec major.minor, SA
Forced exhalation: RA, TrA, ex/internal obliques
.
RR values
Newborn: 30-40 breaths.min
Child: 20-30
Adult: 12-20
normal inspiration is 1/2 long as expiation (1:2)
COPD has longer expiration phase (1:3 or 1:4)
Tachypnea : at least more than 22 breaths/min
Bradypnea: at least less than 10 breaths/min
Hyperpnea: increase in depth and rate of breathing
Increased risk for DM2, HTN, CVD:
if have > 40” waist men or > 35” waist women
ventricular septal defect (VSD)
hole in septum separating R from L ventricles. if too large of hole = too much blood pumped to lungs, HF)
tetralogy of fallot:
- VSD
- pulmonary stenosis
- R ventricular hypertrophy
- Aorta overriding VSD
Can result in infective endocarditis.
cor pulmonale:
AKA R heart failure, pulmonary heart disease.
R Ventricular hypertrophy secondary to lung dysfunction (pulmonary HTN from chronic increased resistance in pulmonary circulation
original RPE scale:
original:
6: very very light
9: very light
11: fairly light
13 somewhat hard
15 hard
17 very hard
19 very very hard
20
**upper limit for early cardiac rehab = RPE 11 to 13
RPE 13-14 = 70% max HR
Revised RPE scale
0 nothing 0.5 very vrery weak 1 very weak 2 weak 3 moderate 4 somewhat strong 5 strong 7 very strong 10 very very strong
EKG:
P wave = atrial depolarization
PR interval: time required for impulse to travel from Syria through conduction system to putkinje fibers SA node to AV node conduction (normal 0.12 - 0.2 sec)
QRS complex: ventricular depolarization and atrial repolarization (normal 0.06 - 0.10 sec)
QT interval: ventricular depolarization and ventricular repolarization (normal 0.2 - 0.4 sec)
ST segment - isolectric period
T wave - ventricular repolarization
Hypo versus hypervolemia
Hypovolemia: dehydration, diarrhrea, severe burns, diuretics
S/sx: ortho hypotension, tachycardia, inc’d temp
Hypervolemia: IV/blood transfusions, heart failure, kidney disease (fluid retention)
S/sx: bilateral LE swelling, ascites, lung fluid
Components of WBCs and functions:
Basophil - allergy
Eosinophil - parasites, CA, allergy
Monocyte - dead and damaged cells, infections
Neutriphil - infection and debris
Lymphocyte - T ( virus, CA, killers) and B (antibodies)
Mechanism of valsalva:
inc’d thoracic pressure, inc’d central venous pressure which results in dec’d venous return from forced expiration against closed glottis.
Results in dec’d CO and dec’d BP detected by baroreceptors which reflexively inc venous return by increesed BP and heart contractility.
Inc’d BP sense by baroreceptros which decrease HR through parasympathetics.
rate-pressure product:
aka double product, HR x SBP
indicator of myocardial O2 consumption
Metabolic Syndrome:
S/Sx: BMI >/= 30 (also for CAD), increased BP, increased waist circumference (>40” men, > 35” women), signs of insulin resistance.
*waist-hip ratio > 0.9 central obesity, CAD risk factor!
Normal breath sounds:
Tracheal and Bronchial: loud tubular sounds over trachea, inspiration expiration, no pause between.
*bronchial sounds heard over distal airways are abnormal = consolidation/compression of lung tissue (facilitates transmission of sound)
Abnormal breath sounds:
Crackles (rales): abnormal, discontinuous, high pitch popping. Often during inspiration at base of lungs.
Pleural friction rub - dry crackling in both inspiration/expiration (When inflamed, visceral/parietal pleura rub together)
Abnormal breath sounds:
Rhonchi: continuous, low pitched, strong gurgling. Both inspiration and expiration.
Stridor: continuous, high pitched wheeze, inspiration or expiration. Indicates upper airway obstruction.
Significant quad weakness = compensate with PF (decrease flex moment of knee)
Use 3rd metacarpal bony landmark for functional reach test.
ST segment depression = cardiac ischemia.
Berg: max 56 (
misc info
Phase 2 Cardiac rehab: exercise prescription
15-20 min initial training phase 1st month.
25-30 min next 3-4 mo (improvement stage)
>/= 40 min after 6 mo (maintenance phase)
*RPE 11-13 on 20 scale is appropriate upper limit during initial phase 2
Lung drainage positions:
ALL lung positions contraindicated if ICP >/= 20mmHg
Apical R/L upper lobes: seated, lean back 30-40deg. Percuss above clavicles.
Posterior segment R upper lobe - 1/4 turn from prone on L side, percuss medial border of R scapula
lung drainage positions:
Lingula L upper lobe - 1/4 turn supine on R side, FOB elevated 12 deg. Percuss L chest between axilla and nipple.
Posterior L upper lobe - 1/4 turn R side prone with HOB elevated 45 deg.
Supplemental o2
Max up to 6L per min.
21% o2 in room air
4% increase in o2 concentration per Inc in L/min
Ejection fraction
EF= stroke volume / left ventricular end diastolic volume
Normal 50-75%
below normal 36-49%
Low
Hyperkalemia
Increased potassium decreases rate and force of heart contraction
(Widened PR interval and QRS, tall T waves)
Hypokalemia
Decreased concentration of potassium produced flattened T waves, prolonged PR and QT intervals )
Arrhythmia may progress to v-fib
Hypermagnesmia
Increased magnesium is a calcium channel blocker which can lead to arrhythmia or cardiac arrest
Postural tachycardia syndrome
Sustained heart rate increase of at least 30 Bpm within 10 min of standing (at least 40 bpm increAse in teenagers)
Aortic valve auscultation
Located on 2nd right intercostal space at sternal border
Pulmonic valve
2nd left intercostal space at sternal border
Tricuspid valve
4th left intercostal space at Sternal border
Mitral valve
5th left intercostal space at mid clavical area
Ortho static hypotension
Initial BP assessment when patient is supine for at least 5 min.
Then stand patient repeat BP assessment immediately and again at 3 minutes.
Positive if systolic drops > 20 or diastolic drops > 10.
MAP
Arterial pressure within large arteries over time, dependent on mean blood flow and arterial compliance.
(Sum systolic + 2 x diastolic) / 3
Normal map is 70-110 mmHg
Levines sign
Patient clenches fist over sternum
Zones of infarction
Zone of Infarction- necrotic non contractile, electrically inert, see pathological q waves
Zone of injury- area immediately adjacent to central zone, noncontractile tissue, undergoing metabolic changes, electrically unstable see Elevatd ST segments
Zone of ischemia- outer area, electrically unstable, see T wave inversion
Wells scale for DVT
Active cancer (treatment ongoing or within 6 months or palliative) +1
Paralysis or recent cast immobilization of LE +1
Recently bedridden for >3 days or major surgery 3 cm compared to a symptomatic leg +1
Pitting edema > in symptomatic leg +1
Previous DVT +1
Collateral superficial veins (non varicose) +1
Alternative diagnosis( >= to DVT) -2
High probability >/= 3
Mod probability 1 or 2
Low probability
Sub max exercise tolerance test
Ended at 85% age predicted max heart rate
Continuous exercise tolerance test
Workload steadily progressed
Step test - increased every 2-3 min to allow for steady state
Ramp test- workload increased every minute patient is not permitted to reach steady state
Without exercise tolerance test, use 208 - 0.7 x age.
70-85% HR max corresponds to 60-80% vo2 max
Semilunar valves
Pulmonary and aortic valVes
Atrioventricular valves
Tricuspid and mitral valves
Hyperoxemia
Increased acidity of blood
Inpatient cardiac rehab
A cute care, 3-5 days.
Initial low intensity (2-3 met) progressing to at least 5 met by discharge.
Limited to 70% Max HR and or 5 mets until 6 weeks post MI
*post surgical progress more rapidly than MI, weight restriction for 6 weeks
Phase 2 outpatient cardiac rehab (subacute)
Frequency 2-3x/week for 30-60 min (5-10 min warmup cool down).
Goal of completing 9 met activity (5 needed for most functional daily activities )
Can strength train after 3 weeks of cardiac rehab (5 weeks post MI or 8 weeks post CABG)
Begin with
Elastic bands 1-3#
Post MI resistance training
Permitted if under 70% Max HR or 5 mets for 6 weeks post MI, caution with use of vaslalva
Resistance training for post cardiac surgery
Lower extremity can be initiated immediately, upper extremity when soft tissue and bony healing has occuredb(6-8 weeks)
S/sx of shock
Pale, gray or blue skin Increased weak pulse Increased RR DecreasedBP Irritability or restlessness Diminishing level of consciousness Nausea or vomiting
Bronchophony
Intense clear sound heard during auscultation even at lung base
Egophony
Nasal or bleating sound heard during auscultation where the “E” sounds are transmitted to to sound like an “A”
Normal blood values summary:
WBC
Hematocrit
Hemoglobin
WBCs 4000-11000 normal
Hematocrit 35%-48%
Hemoglobin 12-16 g/dL
