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Assessment > E2 > Flashcards

E2 Flashcards

1
Q

Which leads show RCA infarct and MI type

A

Leads II, III, aVF

Inferior

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2
Q

Blood administration complications r/t Ca++

Signs and treatment.

A

DECREASED Ca++ (factor IV)
Hypocalcemia b/c citrate
Signs = Chovstick, Trouseau, LOW BP
Give = Ca chloride (faster); Ca gluconate (longer)

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3
Q

Purpose of glycoproteins on the plt

A

Adheres to injured endothelium, collagen and fibrinogen

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4
Q

Causes of right axis deviation?

A 
Vertical heart shift
Marfan's syndrome
Connective tissue disorders
RVH
Anterolateral MI (V3-V6)
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5
Q

Indications for plt transfusion.

A

Thrombocytopenia (low plt)

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6
Q

Lasix class and action

A

Diuretic

Decrease PRELOAD

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7
Q

The CVP waveform that has a diastolic component is

A

a wave
h wave
y descent

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8
Q

What is the most common hereditary blood disorder, and disease process?

A

vWF disorder is a deficiency of F VIII:vWF preventing platelet adhesion

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9
Q

Describe CVP y descent

A

Early diastole
Early vent filling
Diastolic collapse

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10
Q

Charges and chemical makeup of heparin and protamine.

A 
Heparin = NEGATIVE, CHO-
Protamine = POSITIVE CHON+
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11
Q

What are the precordial chest leads?

A

V1 - V6

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12
Q

Cushing’s triad is indicative of what?

A

A late sign of anoxic brain injury d/t sustained increased ICP and progression to herniation and brain death

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13
Q

Pertinent lab work and alterations for DIC

A

Plt = very low (<100,0000)
PT/PTT/TT = very high
Soluble fibrin degradation products = high

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14
Q

5 procoagulant mediators.

A 
Coagulation factors
Collagen
vWF
Fibronectin
Thrombomodulin
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15
Q

What conditions are people at risk for when given RBCs that are not leukoreduced?

A

CMV

TRALI

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16
Q

Describe 1st heart sound
Valves
Cardiac cycle
Sound/volume

A

S1
Valves = closure of mitral and tricuspid valves
Cycle = Onset of systole, begin iso contraction
End of LV filling
Sound= volume proportional to contraction force
Louder w/ vigorous contraction
Softer w/ poor contraction

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17
Q

EKG diagnostic criteria for myocardial ischemia?

A

Inverted, symmetrical T wave

  • *MUST be in 2 contiguous (side-by-side) leads to be diagnostic
  • from baseline
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18
Q

Which leads show circumflex infarct and MI type

A

Leads I, aVL, V5, V6

Lateral

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19
Q

NTG class and action.

A

N+ donor
Vasodilator (veno)
Decrease PRELOAD

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20
Q

Describe 4th heart sound
Due to
Cardiac cycle
Sound/volume

A

S4
Due to= atrial systole
Cycle= end diastole
Sound= before S1

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21
Q

What is the purpose of CVP monitoring

A

Monitor fluid status

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22
Q

What is the positional effect on NIBP?

A

20 cm above = 15 mmHg LOWER

20 cm below = 15 mmHg HIGHER

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23
Q

When is the fibrin clot formed in hemostasis?

A

Secondary hemostasis

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24
Q

What blood component may be necessary when treating HELLP and when

A

Platelets

Give for active bleeding

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25
Q

Characteristic arterial waveforms for aortic regurgitation.

A 
Bisferiens pulse (double peak)
Wide PP
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26
Q

What are 6 factors affecting cardiac supply

A 
Coronary artery anatomy
Diastolic pressure
Diastolic time
O2 extraction
    Hb
    SaO2
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27
Q

If the patient has CAD and requires emergent noncardiac surgery do you proceed?

A

Yes, proceed with surgery

No, proceed to next question.

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28
Q

What would be included in risk reduction for emergent noncardiac surgery?

A

Beta-adrenergic blockers, statins, pain management

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29
Q

What is cryoprecipitate, shelf-life, and factors.

A

Protein fraction off the top of FFP when thawed
Frozen for up to 1 year
Factors = I, vWF, VIII, XIII

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30
Q

Characteristic arterial waveforms for hypertrophic cardiomyopathy.

A

Spike-and-dome pattern (midsystolic obstruction)

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31
Q

Digitalis class and action

A

Cardioglycoside

increase CONTRACTILITY

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32
Q

Medications used to reverse coumadin?

A

1) Vitamin K
2) PCC (prothrombin [II] complex concentrate)
3) Recombinant F VIIa
4) FFP

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33
Q

After one unit of platelets (thrombocytes) how much will it increase?

A

5,000-10,000

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34
Q

Describe the hearts workload with the PV loop widens?

A

Workload increases

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35
Q

What is the purpose of the valsalva maneuver?

A

• To test integrity of surgery and sutures

 “opens alveoli”

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36
Q

Uses and complications of PA catheters.

A

Use: open heart, some neuro cases
Complications: arrhythmias, PA rupture (hemoptysis)

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37
Q

What factors can decrease arterial oxygen content?

A

Hypoxemia

Anema

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38
Q

Is aortic stenosis preload or afterload dependent

A

Afterload dependent

**if afterload is lost then CO is lost

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39
Q

What are unstable coronary syndromes that are contraindicated when proceeding with nonemergent noncardiac procedures? (3)

A
  1. Unstable or severe angina at rest, increase symptoms, duration >30 mins and symptoms not responsive to TX
  2. Acute MI w/in past 7 days–> postpone elective surgery
  3. Recent MI w/in 7-30 days w/ myocardium risk (+stress test and symptoms)
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40
Q 
How much does a unit of 
RBC
FFP
Cryo
Plt
Increase their respective labs?
A 
RBC 
--INC Hgb 1 g/dL
--INC Hct 3%
Cryo
--50 mg/dL
Plt
--INC plt by 5K-10K
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41
Q

Biggest problem with SCD?

A

Oxygenation
Symptoms start
PaO2 40 = 75% SpO2

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42
Q

What are the landmarks for valve auscultation

A

Aortic Valve Area = 2nd R intercostal space (ICS), right sternal border
Pulmonic valve = 2nd L ICS, L sternal border
Erb’s Point = 3rd left ICS, left sternal border ( where S2 is heard much better)
Tricuspid = 4th left ICS, left sternal border
Mitral valve = 5th ICS, left mid-clavicular line

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43
Q

What substance mediates the vascular phase?

A

Endothelin - primary hormone

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44
Q

Two thrombogenic factors contained in the media?

A

Collagen

Fibronectin

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45
Q

What are severe valvular diseases that are contraindicated when proceeding with nonemergent noncardiac procedures?

A

Severe aortic or mitral stenosis

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46
Q

Severe hypotension in a patient with aortic stenosis can result in?

A

Myocardial injury and death

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47
Q

What mediators are released during aggregation? What is their purpose?

A

alpha/dense granules
Contractile granuels
Thrombin
Others

Purpose = to promote procoagulant activity

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48
Q

Purpose of the intima layer?

A

Separates flowing blood from the vessel

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49
Q

MI location and artery when leads II, III and aVF involved

A

Inferior

RCA (posterior descending)

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50
Q

Which pathways of the clotting cascade does FFP effect and why?

A

Intrinsic
Extrinsic
Common
Because FFP has all clotting factors

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51
Q

Describe 3rd heart sound
due to
Cardiac cycle
Sound/volume

A

S3
Due to= flaccid, inelastic heart (HF)
Cycle= middle 1/3 diastole (after S2)
Sound= gallop rhythm (rumbling)

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52
Q

EKG diagnostic criteria for right atrial hypertrophy.

A

Initial diphasic P wave component larger in V1

Initial diphasic P wave > 2.5 mm in ANY lead

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53
Q

What is HELLP syndrome?

A

HELLP=In pregnant women

  • Red cell HEMOLYSIS and HTN (H)
  • ELEVATED LIVER enzyme level (EL)
  • LOW PLATELET count (LP)
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54
Q

When is cryo used in vWF disorder

A

If pt is not responsive to DDAVP

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55
Q

Which blood component has antithrombin III

A 
FFP 
antithrombin III (tissue factor)
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56
Q

What is sequestration crisis in SCD and manifestations?

A

Splenic RBC removal GREATER than RBC production
Manifestations:
Severe anemia
Hemodynamic instability

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57
Q

Complications of CVC placement

A

PTX, nerve injury, cardiac tamopnade, chylothorax (lymph injury on LEFT side neck)

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58
Q

What view do the limb leads vs precordial leads show of the heart?

A

limb leads = frontal view

precordial leads = horizontal/transverse view

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59
Q

Comorbid causes of right ventricular hypertrophy?

A

Pulmonary HTN
–> from LA problems?
Pulmonic valve stenosis
Ends stage mitral regurg?

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60
Q

What are active cardiac conditions that may affect or postpone noncardiac surgeries? (4)

A
  1. Unstable coronary syndrome
  2. Decompensated HF
  3. Significant arrhythmias
  4. Severe valvular disease
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61
Q

Characteristic arterial waveforms for systolic LV failure.

A

Pulsus alternans (alternating PP amplitude)

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62
Q

What happens over time to 2,3-DPG in blood?

A

It decreases
Shifts oxyhgb curve LEFT
Impairs O2 delivery

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63
Q

Acute chest syndrome in SCD is due to

A

Lung infiltration

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64
Q

Vitamin K use, onset, drawbacks?

A 
Use = coumadin reversal
Onset = 6-8 hrs
drawback = Not as rapid as other reversals
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65
Q

What is the role of collagen in hemostasis?

A

Potent and important stimulus for platelet attachment in injured vessel wall

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66
Q

Factor V leiden is due to

A

Mutation of factor V that is not responsive to activated protein C inactivation of F V

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67
Q

Mag sulfate dose
Loading
Maintenance
Therapeutic range

A

Loading = 4g over 5 mins
Maintenance = 1-2 g/hr
Therapeutic range = 4-6 mEq/L

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68
Q

Surgical considerations for pt with vWF disorder (avoid)

A 
Avoid:
trauma
Arterial puncture
laryngeal trauma during intubation
IM injection
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69
Q

EKG evidence of “old” MI

A

Q wave in contiguous leads

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70
Q

What can occur with valsalva?

A

Stimulates baroreceptors

Drop in HR, BP, contractility and vasodilation due to increased intrathoracic pressure

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71
Q

Confirmation of CVC placement includes?

A

Aspirated blood is dark = venous

Xray = TIP at T4 - T5 interspace

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72
Q

What preop home medication is important to hold in pts with AS and why?

A

ACE-i (-prils)

To prevent hypotension in OR

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73
Q

What structure on the plt is derived of phospholipids

A

TXA

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74
Q 
Regarding coronary supply and demand, which increases coronary blood flow
Aortic transvalular gradient of 4 mmHg
Elevated HR
Increased pulse pressure
Coronary vasoconstrition
A

Aortic transvalvular gradient of 4 mmHg

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75
Q

Risks of neuraxial block in pts with vWF

A

Increased risk for
hematoma
Compression of neurological structures

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76
Q

4 blood component therapy

A

RBC
FFP
Cryo
PLT

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77
Q

Diastolic HF

etiology, hallmark, preload, afterload, contractility, HR, LV geometry

A

Etiology=Filling problem, MI, valve STENOSIS, HTN, HYPERTROPHIC cardiomyopathy, cor pulmonale, obesity
Hallmark= normal EF w/HIGH LVEDP, low compliance,
Preload=Volume needed to stretch noncompliant LV
LVEDP doesn’t correlate to LVEDV
Afterload=Keep elevated to perfuse thick myocardium, maintain CPP
Contractility=Normal
HR=Slow/normal to increase diastolic filling time and CPP
LV geometry= Concentric hypertrophy (THICK)

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78
Q

Indications(4) and possible findings(3) in a preop echo for SCD pts.

A

Indication = limited physical ability, hypoxemia, respiratory distress, symptoms of cor pulmonale

Common findings = LVH, RV dilation, atrial enlargement

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79
Q

Incidence of asthma and pulmonary HTN in SCD pts and mortality

A

Asthma = 50%
Pulm HTN = 10%
Mortality greatly increased when asthma and pulm HTN present

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80
Q

Cryo is used to treat…

A

Hypofibrinogenemia

Low fibrinogen

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81
Q

How is the baroreceptor stimulus integrated?

A

Inc/Dec action potentials in AFFERENT vagus nerve X (AORTIC ARCH) or herring’s nerve IX to CV centers of medulla in brainstem

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82
Q

What is the bainbridge reflex stimulus?

A

Stretch receptors in the right atrial wall and cavoatrial junction

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83
Q

Anesthetic considerations when giving Mag?

A

1) Mag inhibits ACh release at NMJ
2) Use MRs cautiously
3) Decrease use of sedative and opiates (b/c hypoventilation and hemodynamic instability)
3) Exaggerated hypotensive response to regional

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84
Q

Two main external projections types on plts

A

Glycoproteins

Phospholipids

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85
Q

What vessel action mediators do endothelial cells release?

A

Vasoconstrictors (TXA2, ADP)

Vasodilators (NO, prostacyclin)

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86
Q

What is aplastic crisis, causes and what can it lead to?

A 
Occurs when RBC production is suppressed 
Causes:
Mild bone marrow suppression
Viral infection (parovirus B19)
Leads to = rapid onset of anemia
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87
Q

Universal donor and recipient

A 
Donor = O-
Recipient = AB+
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88
Q

2 drugs that affect preload

A

Lasix

NTG

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89
Q

What is the effect of the bainbridge reflex? autonomic response

A

PSNS stimulation

DEC HR and BP

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90
Q

What is the definitive treatment for HELLP?

A

Deliver the baby

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91
Q

What is acute chest syndrome (ACS) in the SCD pt? The incidences, Treatment and preventative measures?

A 
Lung infiltration (resembles PNA) w/ pain, no EKG changes, and pulmonary signs
Incidence = r/t infection, higher in children
Treatment = supportive (pain meds, hydration)
Preventative = Transfusions, post-op IS
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92
Q

What is the purpose of actin/myosin and thrombosthenin in the plt?

A 
Actin/Myosin = contraction to form plt plug
Thrombosthenin = plt contraction
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93
Q

What are the 6 components to the Lee revised cardiac risk index and purpose?

A

Purpose = Greater # of predictors, higher ricsk of cardiac complications

1) High-risk surgery
2) Ischemic heart dx
3) H/o CHF
4) H/O CVA/TIA
5) DM needing insulin
6) Crt >2.0 mg/dL

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94
Q

What are positional effects on arterial line BP

A

There is no effect on A-Line BP reading

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95
Q

What action would be important prior to extubation if herniation/cushings triad is suspected?

A
  • Trial respirations

- Irregular respirations are masked by mechanical ventilation

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96
Q

Why is there a time frame for blood transfusion after removal from cooler?

A

Prevents bacterial growth

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97
Q

What are phosphate, dextrose and adenine components for in blood storage?

A 
Phosphate = buffer
Dextrose = fuel source
Adenine = substrate for ATP synthesis
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98
Q

Clinical features of vWF disorder?

A

EAsy bruising
Recurrent epistaxis
Menorrhagia

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99
Q

Systolic HF

etiology, hallmark, preload, afterload, contractility, HR, LV geometry

A

Etiology = Pump problem, MI, valve INSUFFICIENCY, DILATED cardiomyopathy
Hallmark = Low EF w/ high LVEDV d/t volume overload
Preload= Already high
Afterload= DEC to reduce myocardial workload, maintain CPP
Contractility = augment
HR = Usually high d/t INC SNS tone and to preserve CO
LV Geometry = eccentric hypertrophy (dilated)

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100
Q

Characteristic arterial waveforms for cardiac tamponade.

A

Pulsus paradoxus (huge decrease in SBP during INSpiration)

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101
Q

Which leads show LAD infarct & MI type

A

Leads V1, V2, V3, V4

Septal, anerior

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102
Q

EKG diagnostic criteria for left ventricular hypertrophy?

A

(S in V1) + (R in V5) = > 35 mm

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103
Q

Diagnosis criteria for HTN and causes?

A

Diagnosis = BP must be obtained on 2 separate occasions atleast 1-2 wks apart
Causes = INCREASE CO/SVR
-Most likely due to HIGH SVR b/c INC vascular smooth muscle tone

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104
Q

Management and treatment for DIC

A 
Management = correct underlying cause
Treatment = blood component replacement with coag factors and plts
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105
Q

What happens to 2,3-DPG with blood storage?

A

Prolong storage DECREASES 2,3-DPG
LEFT shift oxyhgb dissociation curve
Impairs O2 delivery

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106
Q

When pt requires surgery and it is not emergent, what is the next consideration?

A

Does the patient have active cardiac conditions

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107
Q

What are 7 structures insideof plt that are used for hemostais?

A

1) Actin/Myosin
2) ADP
3) Ca++
4) Fibrin-stabilizing factor
5) Serotonin
6) Growth factor
7) Thrombosthenin

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108
Q

What is the integration process for the oculocardiac reflex?

A

 The afferent path (sensory) –> trigeminal nerve (V1-opthalmic branch)
 The efferent branch (motor) –> vagus (X)

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109
Q

Platelets are able to participate in the activation of other platelets in the surroundings due to which structure in the plt cytoplasm

A

Serotonin

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110
Q

EKG evidence of right axis deviation.

A

QRS in aVF = positive

QRS in I = negative

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111
Q

To prevent hypotension and tachycardia in a pt with AS, what medications may be given

A

BP: alpha-adrenergic agonist (neosynephrin)
HR: beta blocker

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112
Q

Septal MI leads, artery, side of heart

A 
Leads = V1, V2
Artery = LAD
Side = Left
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113
Q

What are 2 endothelial mediators that vasoconstrict?

A

Thromboxane A2
Adenosine diphosphate (ADP)
Serotonin (5HT)

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114
Q

2 drugs that affect afterload

A

Neosynephrine

Nipride

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115
Q

Adrenergic receptor drug treatment for HTN

A

alpha-1 antagonist
beta-1 antagonists
Mixed alpha-1/beta-1/2 antagonists
alpha-2 agonists

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116
Q

Noninvasive testing for CAD pts with cardiac risk factors?

A 
Stress test (pts w/ 1-2 predictors)
Exercise or pharmacological
Pharmacological stress test for pts that can't exercise, have PM, severe bradycardia, on high dose beta-blockers
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117
Q

What is the normal progression of inflection/deflection of precordial leads V1, V3, V6?

A 
V1 = negative
V3 = half/half
V6 = positive
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118
Q

Pharmacological treatment of HTN, drug classes

A

Adrenergic receptors drugs
CCBs
Drugs targeting kidneys (ACE-i, ARBs, diuretics)
Drugs targeting myocardium or vasculature

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119
Q

Protamine structre?

A

Positive polypeptide (amino acid)

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120
Q

What is the vascular phase of hemostasis?

A

VASCULAR SPASM - from damage

Generally localized to injured area

Very short–progresses to next phase quickly

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121
Q

What are the 3 vessel layers (in to out)?

A

Intima
media
Adventitia

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122
Q

What is prostacyclin function?

A

Vasodilates
Inhibits aggregation
promotes smooth muscle relaxation

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123
Q

What is the integration process for the celiac reflex?

A

Efferent signal via vagus nerve

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124
Q

The V1 electrode should be positioned where?

A

4th ICS, right of the sternum

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125
Q

What CHF qualifications are contraindicated when proceeding with nonemergent noncardiac procedures?

A

New onset CHF
NYHA class IV
–Based on exercise tolerance and associated clinical symptoms

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126
Q

How is the chemoreceptor stimulus integrated?

A

Afferent impulses sent via carotid sinus herring’s nerve IX AND vagus nerve X
-to chemosensitive area of medulla

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127
Q

What are the best intraop strategies for mitral regurg?

A

Maintain contractility

Decrease SVR

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128
Q

What storage components are used in blood storage?

A

Citrate
Phosphate
Dextrose
Adenine

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129
Q

Pressure vs volume overload valvular diseases

A

Pressure overload = STENOSIS (mitral and aortic)

Volume overload = REGURGITATION or insufficiency (mitral and aortic)

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130
Q

What vessels supply the coronary blood flow?

A

The left and right coronary arteries supply the myocardium with oxygenated blood

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131
Q

What is the most likely lead to monitor on all patients?

A

II

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132
Q

Pathophysiology of factor V leiden and cause?

A

Patho = F V (proacceleran) is resistant and not inactivated by activated protein C like normal
This leads to continued fibrin clotting
Cuause = genetic mutation of F V

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133
Q

How is the oculocardiac reflex stimulated?

A

 Traction on the extraocular muscles

 Leads to: dec BP and a reflex dec HR ,and arrhythmias

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134
Q

Purpose of the adventitia layer

A

Control of blood flow by influencing vasodilation/constriction

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135
Q

What does a h/o sequestration crisis indicate for SCD pts.

A

Indication for early splenectomy

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136
Q

Monitoring and reversal of heparin? How does reversal work?

A

Monitor PTT and ACT
Reversal = Protamine rapid
Protamine is a positive polypeptide (amino acid) that binds to negative heparin
Forms stable complex and neutralizes heparin

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137
Q

Ketorolac administration lab considerations for SCD pts?

A

Know Crt and Plt

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138
Q

Most common drug for vWF disorder and what do you give if it doesn’t work?

A

1st line = DDAVP
then cryoprecipitate
Then Factor VIII

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139
Q

Where is atrial hypertrophy going to be evident (wave and lead)?

A 
Wave = p 
lead = V1
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140
Q

Nipride class and action

A

N+ donor

Vasodilator to decrease AFTERLOAD

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141
Q

What are 2 endothelial mediators of vasodilation

A

NO

Prostacyclin

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142
Q

Describe PT, PTT, and BT in vWF disorder?

A

PT and aPTT normal

BT prolonged

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143
Q

Aortic stenosis severity is dependent on…

A

Increased transvalvular gradient and decreased valve size

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144
Q

Describe CVP waveform for A-Fib

A

Loss of a wave d/t poor atrial contraction

Prominent c wave

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145
Q

Treatment of vWF disorder

A

Correct vWF deficiency
Use desmopressin
Transfuse cryo
Give specific factor VIII

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146
Q

6 anesthesia periop considerations for SCD?

A

1) Preop hgb,
2) Preop echo (LV hypertrophy, RV dilation, atrial enlargement)
3) Preop transfusion to get to hgb 10
4) Intraop transfusion–keep hgb 10
5) Maintain normothermia
6) Maintain hydration

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147
Q

Antifibrinolytics MOA and agents?

A

MOA = inhibits conversion of plasminogen to plasmin
promotes clotting
Agents = TXA, aminocaproix acid, aprotinin

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148
Q

What are the considerations when giving narcotics to SCD pts?

A

Induced hypoventilation
Causing hypercardia and hypoxemia (worsening)
Can exacerbate ACS

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149
Q

Prophylaxis treatments for F V leiden and why

A

Anticoaglant to prevent thromboses

Give Warfarin, UFH, LMWH

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150
Q

Milrinone class and action.

A

PDE-i

increases CONTRACTILITY

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151
Q

What is the function of GpIb

A

To attach the plt to vWF

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152
Q

Side effects of DDAVP administration

A 
Headache
rubor
hypotension
tachycardia
HYPONATREMIA
WATER INTOXICATION
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153
Q

Describe CVP h wave, cardiac cycle and EKG correlation

A

Mid to late diastole
Diastolic plateau
Only present during bradycardia
Before P wave

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154
Q

What is the function of tissue pathway factor inhibitor?

A

Inhibits tissue factor III

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155
Q

Drugs that target kidneys to treat HTN.

A

ACE-i
ARBs
Loop, K sparing and thiazide diuretics
Aldosterone antagonist

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156
Q

How is plt obtained and supplied and what is the increase in plt after one unit transfusion?

A

Platelet only, obtained from whole blood or platepheresis donation
One bag= random value
One bag pheresis = 250 - 300 mL
One unit = INCREASE plt 5k-10k

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157
Q

What phase hemostasis are platelets activated?

A

Primary hemostasis

158
Q

What are 5 clinical features/manifestation of SCD?

A 
Vaso-occlusive crisis (VOC)
Acute Chest syndrome (ACD)
Sequestration crisis
Aplastic crisis
Asthma and pulmonary HTN
159
Q

What is the integration of the stimulus for the bainbridge reflex?

A

Changes in RIGHT-sided filling pressure send VAGAL nerve X afferent signals to CV centers of medulla

160
Q

When does HF occur, what is cardiac remodeling and how can that be reversed?

A 
HF = when ventricles are unable to fill or pump
Remodeling = heart changes shape, size and function to preserve CO, eventually fails
Reversal = ACE-i, aldosterone inhibitors (spironolactone)
161
Q

What is the second phase of plt response?

A

ACTIVATION

162
Q

Increased myocardial O2 demand causes (3) and interventions (3)

A 
Causes = INC HR/BP/PAOP
Intervention = beta blockers, INC anesthetic, vasodilators (NTG)
163
Q

MI location and artery when leads V1, V2 involved

A

Septal

LAD

164
Q

Describe CVP a wave

A

End diastole
Atrial contraction
P wave

165
Q

Describe 2nd heart sound
Valves
Cardiac cycle
Sound/volume

A

S2
Valves= Closure of aortic and pulmonary valves
Cycle= Onset of diastole, begin iso relaxation
End of LV ejection
Sound= volume proportional to LV pressure
Louder w/ HTN, softer w/ hypotension

166
Q

What are high risk vascular cases and estimated risk of cardiac death or nonfatal MI?

A

> 5%
Aortic and other major vascular surgeries
Peripheral vascular surgery

167
Q

What makes up the 1% other solutes in plasma? (5)

A

Ions, nutrients, waste products, gases, regulatory substances

168
Q

MI location and artery when leads I, aVL, V5, V6 involved

A

Lateral

Circumflex

169
Q

Describe the workload changes of the PV loop when height increases

A

Workload increases

170
Q

Once preop risk stratification is complete for CAD pt what are 3 therapeutic options before elective noncardiac surgery?

A

1) Revascularization by surgery (+3 factors)
2) Revascularization by PCI w/ stent (1-2 factors)
3) Optimal medical management

171
Q

Indications for RBC transfusion.

A

Bleeding

To increase O2 carrying capacity

172
Q

What factors decrease myocardial O2 delivery and coronary flow and can lead to ischemia? (8)

A
  1. Tachycardia
  2. Decreased PaO2
  3. Decreased O2 extraction
  4. DEC aortic pressure
  5. INC EDP
  6. Coronary vessel diameter
  7. DEC Hgb
  8. DEC P50 (left shift)
173
Q

Pt w/ CAD is having a high risk surgery, how do you proceed and what does the next step involve?

A

Assess patient functionality
Functional Capacity = MET (metabolic equivalent units)
O2 consumption at rest = 3.5 ml/kg/min = 1 MET
Good =/> 4 METs
Proceed to surgery

174
Q

MOA of fibrinolytics and drug examples?

A

MOA = Converts plasminogen to plasmin which cleaves fibrin (Ia) and causes clot dissolution
Drugs = tissue plasminogen activator (tPA)
streptokinase (SK)
urokinase (UK)

175
Q

What are the 3 phases of platelet formation?

A

Adherence
Activation
Aggregation

176
Q

What factors affect decreased coronary flow?

A
  1. Tachycardia
  2. Decreased aortic pressure
  3. decreased vessel diamter (spasm/hypocapnia)
  4. Increased EDP
177
Q

Drugs that target myocardium or vasculature for HTN

A

dihydropyridines, non-dyhydropyridines
Areriodilators
Venodilators

178
Q

What factors can increase O2 demand?

A 
Tachycardia
HTN (INC afterload)
SNS stimulation ("light")
INC wall tension
INC EDV
INC afterload
INC contractility
179
Q

What is the equation for cardiac output and the normal value

A 
CO = SV X HR
CO = (EDV - ESV) x HR

5 - 6 L/min

180
Q

Where is an arterial line zeroed

A

Phlebostatic axis

181
Q

How is the Bezold - Jarisch Reflex stimulated?

A

By irritants stimulation in the LV via chemo/mechanoreceptors

182
Q

Describe the phases (begin to end) of oscillation when taking a cuff pressure.

A

Osillation:
•begins at systolic pressure
•peaks at mean arterial pressure
•disappears once again at diastolic pressure.

183
Q

Neosynephrine action

A

Vasoconstrictor
Increase SVR
Increase AFTERLOAD
alpha-adrenergic agonist

184
Q

Normal EF and equation

A

SV / EDV
(EDV-ESV) / EDV
60-70%

185
Q

What is the effect seen with the bainbridge reflex?

A

Inhibition of PSNS

Activates SNS actions

186
Q

EKG diagnostic criteria for myocardial injury/infarction?

A

ST segment elevation

  • off of isoelectric line
  • -S wave does not return to isoelectric line
187
Q

How does increased thoracic pressure from valsalva affect CO and VR?

A

Decreased CO

Decreased VR

188
Q

What is the purpose of ADP and Ca++ in the plt?

A 
ADP = Plt activation and aggregation
Ca++ = Role in coagulation cascade (F IV)
189
Q

Causes of right atrial hypertrophy.

A

Tricuspid regurgitation

Pulmonary hypertension

190
Q

How long do you have after blood is removed from the cooler to transfuse it?

A

30 minutes

Needs to be used within 30 minutes

191
Q

What makes up PRBCs?

A

RBCs from whole blood
Plasma removed
Contains leukocytes unless leukoreduced

192
Q

Describe CVP waveform for cardiac tamponade.

A

Dominant x descent

Attenuated y descent

193
Q

What is the amount of coronary blood flow per minutes and what percentage of CO is it?

A

Coronary blood flow is 225-250 mL/min or roughly 4-7% of the CO

194
Q

What occurs if the plt plug is not enough for the injury?

A

Progression to secondary hemostasis and clotting cascade

195
Q

Considerations for pre, intra and postop RBC transfusion in the SCD pt.

A

Preop = Low Hgb, INCREASE to 10 g/dL
what surgery?

Intraop = significant blood loss, maintain hgb >10 g/dL

196
Q

Describe CVP v wave

A

Late systole
Systolic filling of the RA
After T wave

197
Q

Indications for FFP transfusion? (8)

A

1) Correct inherited and acquired factor deficiencies when PT/aPTT >1.5 times the control, bleeding, or prior to surgery
2) Liver dysfunction w/ bleeding
3) DIC w/ bleeding
4) Microvascular bleeding associated w/ MT and EBL >1 lood volume
5) Reversal of Vit K antagonists
6) Heparin resistance 2/2 antithrombin deficiency if AT not available
7) Thrombotic pathologies (HELLP, TTP)
8) Hereditary angioedema if C1-esterase inhib not available

198
Q

Briefly, what are the purposes of each hemostasis phase?

A 
Vascular = vascular spasm
Primary = Form plt plug
Secondary = Coagulation cascade and fibrin formation
Fibrinolysis = Clot lysis
199
Q

How much volume does atrial kick provide and when does this happen

A

5 - 10%

At the end of phase 1 filling

200
Q

Process of NO’s action?

A

NO diffuses from endothelial cells into muscle cell (adventitia)

  • Activates soluble guanylate cyclase
  • 2nd messenger cGMP produced
  • cGMP causes muscle relaxation
201
Q

What occurs during activation phase of plt response? (5)

A

1) TF causes conformational change of plt
2) active plt swells, is oval and irregular shape
3) GpIIb/IIIa surface
4) GpIIb/IIIa adhere other activated plts together
5) Plt seal site of injury

202
Q

What is the effect of the B-J refelx

A

Efferent impulses sent to heart via CN X
PSNS stimulation: DEC HR, BP
Coronary dilation

203
Q

What proteins are contained in plasma, from greatest to least? (4)

A

Albumin
Globulin
Fibrinogen
Prothrombin

204
Q

What leads to TRALI and how can it be prevented?

A

ABO mismatch

Leukoreduced RBCs

205
Q

What is the normal life span of an RBC and change in SCD?

A 
Normal = 120 days
SCD = 12-17 days
206
Q

Preop considerations for vWF disorders or any bleeding disorder?

A 
type and screen prior to surgery
A-line??
Hematologist assessment
Infuse DDAVP 60 min prior to surgery
Normalize bleeding time by confirming F VIII level improvement prior surgery
207
Q

How do arterial waveforms compare between aortic arch (proximal site) and femoral artery (distal site)?

A

•Wider pulse pressure (fem vs aorta)
-HI SBP and LOW DBP
•A delayed upstroke (femoral)
•A delayed, slurred dicrotic notch (femoral)
•Prominent dicrotic notch for aortic wave
•More prominent diastolic wave (femoral)

208
Q

Hyponatremia can result from what blood disorder treatment & can eventually lead to…

A

vWF disorder
DDAVP administration
Seizures

209
Q

Where is ventricular hypertrophy going to be evident (wave and lead)? Positive or negative?

A 
Wave = QRS
Lead = V1
210
Q

Another name for platelet?

A

Thrombocytes

211
Q

EKG diagnostic criteria for right ventricular hypertrophy?

A

V1 QRS is POSITIVE

all other precordial leads QRS become progressively smaller

212
Q

Pathophysiology of heparin-induced thrombocytopenia (HIT), clinical presentation, and condition results?

A

Patho = Autoimmune-mediated drug reaction in ~5% of pts receiving heparin
Mediated by IgG antibody
Immune complex = IgG + platelet fact 4 (PF4) and heparin
Presentation = Thrombocytopenia 2/in 5-14 days of heparin
PLT <100,000
Results in = plt activation, potential for venous and arterial thromboses

213
Q

1st line treatment for vWF

A

DDAVP

214
Q

Diagnostic criteria for a Q wave or old MI?

A 
Q wave must be
-1 mm wide
-2 mm deep (neg)
OR
-1/3 of QRS tall
AND
-2 side-by-side leads
215
Q

Why are steroids given to moms with HELLP syndrome?

A

To help mature baby’s lungs by increasing surfactant production
May increase platelet count for mom

216
Q

Pt with CAD passes functional capacity assessment, what is the next step and what should be considered(5)?

A 
Assess clinical predictors 
1) Ischemic heart dx
2) compensated or prior HF
3) Cerebrovascular dx (CVA, TIA)
4) DM
5) Renal insufficiency 
No clinical predictors? proceed with surgery
217
Q

What can poor R wave progression indicate? Where is it seen?

A
  • Old MI if Q wave not present
  • Seen in PRECORDIAL leads
  • A lot of dead tissue that electricity has to go around
218
Q

Purpose of CPDA in blood storage?

A

Preservative to prolong blood component storage
Citrate = Ca++ chelation & prevents clotting (Factor IV)
Phosphate = buffer
Dextrose = fuel source
Adenine = substrate for ATP synthesis

219
Q

Heparin-induced thrombocytopenia manifests in what lab specifically?

A

Low platelets

220
Q

What is a Q wave?

A

When QRS is deflected negative FIRST
-1mm wide
-2 mm deep
OR 1/3 height/depth of QRS

221
Q

When do alterations to hgb occur in SCD? How does it become unstable?

A

Alteration = when hgb S is exposed to low O2 concentration
Unstable = Hgb polymerizes w/ other Hgb S molecules
-forms a crystalline gel which deforms the hgb into characteristic sickle shape

222
Q

Heparin MOA?

A

Thrombin (F II) inhibitor
So fibrinogen (I) can’t conert to fibrin (Ia)
Activates antithrombin III

223
Q

EKG evidence of left axis deviation.

A

QRS in aVF = negative

QRS in I = positive

224
Q

What are eicosanoids?

A 
Lipids that form:
-Prostaglandins/cyclins
-Leukotrienes
-Thromboxanes
(From the AracA pathway)
225
Q

What is NOs function?

A

vasodilation

promotes smooth muscle relaxation

226
Q

Diastolic HF treatments for
preload
afterload
contractility

A 
Preload = TEE to assess
Afterload = neo (alpha-1 antag)
227
Q

How to prevent 5 triggers for sickling?

A

Preoxygenate
Optimize hydration with blood (hgb 10) then fluids
Warm room and maintain normothermia

228
Q

What components are in plasma?

A

Water
proteins
Solutes

229
Q

What occurs in plt adherence? (3)

A

1) vFW mobilizes from endothelial cell and emerges
2) GpIB surface on plt
3) GpIb attaches to vWF and attracts other plts

230
Q

6 Causes and treatment for secondary HTN.

A 
Causes=coarctation of aorta
renovascular dx
hyperadrenocorticism
hyperaldosteronism
pheochromocytoma
pregnancy
Treatment = treat the cause
231
Q

Inferior MI leads, artery, side of heart

A 
Leads = II, III, aVF
Artery = RCA (posterior descending)
Side = Right
232
Q

What makes up formed elements and normal ranges?

A

Platelets = 140K-340K
Leukocytes (WBCs) = 5k-10k
Erythrocytes (RBCs) = 4.2–6.2 million

233
Q

Risks and treatment of HIT?

A

Risks = thrombosis (30-75%)
Treatment = DC heparin** (catheters, flushes and LMWH)
Alternative non-heparin anticoag
-Direct thrombin inhibitors
–Bivalirudin, lepirudin, argatroban
-Fondaparinux (synthetic Factor Xa inhibitor) for VTE

234
Q

Causes of DIC

A 
Underlying disorders
Trauma
amniotic fluid embolus
malignancy
sepsis
incompatible blood transfusion
235
Q

What are 8 cardiac reflexes?

A 
	Baroreceptor
	Valsalva
	Cushing
	Chemoreceptor
	Bainbridge reflex
	Oculocardiac
	Celiac
	Bezolh-Jarish
236
Q

What effect occurs with the celiac reflex? autonomic response?

A

PSNS stimulation

DEC HR and BP

237
Q

Causes of left atrial hypertrophy?

A

Mitral regurgitation

Long-term HTN

238
Q

Aortic stenosis grades, velocity, mean pressure gradient and valve area

A

m/sec mmHg cm2
Mild: <3 m/sec, <25 mmHg, >1.5 cm2
Mod: 3-4 25-40 1.0-1.5
Severe: 4-4.5 40-50 0.7-1.0
Critical >4.5 >50 <0.7

239
Q

Oxygen delivery to the cell is a product of…

A

CO

Arteerial O2 content

240
Q

What are significant arrhythmias that are contraindicated when proceeding with nonemergent noncardiac procedures?

A 
Mobitz II
3rd degree HB
SVT or AFib RVR (new onset)
Symptomatic ventric arrhythmia or brady
New V-Tach
241
Q

What makes up whole blood and percentage by volume?

A

Plasma = 55%

Formed elements = 45%

242
Q

What is the function of GpIIb/IIIa?

A

Links activated plt together

243
Q

4 phases of hemostasis and coagulation.

A
  1. Vascular phase
  2. Primary Hemostasis
  3. Secondary Hemostasis
  4. Fibrinolysis
244
Q

What is myocardial ischemia indicative of?

A

DECREASED O2 supply to myocardium from coronary arteries

245
Q

What are some platelet properties, normal level and life-span?

A

+Round and disk-like
+freely circulating
+Normal levels 150K-300K
+1-2 week lifespan

246
Q

What process activates initial platelets and clotting factors? What is initially formed?

A

Damage to the endothelium

Platelet plug

247
Q

What do endothelins do? (3)

A

+Stimulate smooth muscle contraction

+Stimulate cell division of endothelial cells, smooth muscle cells and fibroblasts

+Aids in repairing damaged site

248
Q

What is the valsalva maneuver?

A

 Forced expiration against a closed glottis

249
Q

What is the shape of the p wave for atrial hypertrophy

A

diphasic

250
Q

When do most periop MIs occur?

A

Most perioperative MI occurs 24-48 hours post op – accounts for 20% mortality

251
Q

A lateral wall MI would suggest a blockage in what coronary artery and be evident in which leads?

A

Circumflex

I, aVL, V5, V6

252
Q

Possible treatment to decrease or abolish inverted T wave?

A

INCREASE supply
DECREASE demand
(rest, vasodilate etc)

253
Q

How many liters of blood loss before fibrinogen drops and why?

A

1.5 L

Fibrinogen is first factor that is used up in hemostasis

254
Q

What is the effect of the chemoreceptor reflex? Autonomic response

A
  1. Medulla responds by stimulating respiratory centers to INC/DEC respiratory drive
  2. Inhibition of PSNS to INC HR and contractility
255
Q

What pathways of the clotting cascade does cryoprecipitate effect and why?

A

Intrinsic (factor VIII:vWF, VIII:C)

Common (I, XIII)

256
Q

What is the mechanism of acute chest syndrome, how is it diagnosed, and the mortality rate?

A 
Mechanism:
Thrombosis, embolism, infection
Diagnosis:
New lung infiltrates on CXR (generally 1 lung segment) WITH--chest pain, cough, dyspnea, wheezing, hypoxemia
Mortality = 20%
257
Q

MI vs pericarditis 12-lead and symptoms.

A

Pericarditis has ST elevation in ALL leads

and pain is sharp NOT pressure

258
Q

What type of leads are the 1st three leads in a 12-lead EKG?

A

Bipolar limb leads

259
Q

What is primary hemostasis?

A

Initiated in vascular phase isn’t sufficient

Injured vessel attract platelets

Forms platelet plug

260
Q

Why is FFP used for hemostasis?

A

Contains ALL clotting factors EXCEPT platelets

261
Q

Causes of left axis deviation

A

Inferior MI
LVH
Obesity
Pregnancy

262
Q

Oxygen consumption of a 70 kg pt is 1225 ml/min. How many METs is this? Explain.

A

5 METS
O2 consumption is 3.5 ml/kg/min in 1 MET.
70 kg x 3.5 = 245 (1 MET)
1225/245 = 5 METS

263
Q

What are the limb leads? Are they bipolar or unipolar?

A 
Bipolar = I, II, II
Unipolar = aVR, aVF, aVL
264
Q

What substances do the endothelial cells secrete or synthesize?

A

Procoagulants
Anticoagulants
Fibrinolytics

265
Q

What are the effects of the baroreceptor reflex?

A
  1. Inc/Dec action potentials in efferent vagus nerve X to change HR and CO
  2. Inc/Dec in APs in SNS to
    a. HEART (contractility/SV/CO)
    b. venous vessels (venodilation and constriction, VR, CO),
    c. arterial vessels (SVR)
  3. Change in BP
266
Q

Which of the 8 cardiac reflexes is cardio protective?

A

Bezold-Jarisch reflex

267
Q

What are some causes of tachycardia in the OR?

A 
Hypovolemia (blood loss)
hyperthermia
Alertrness
Pain
Stenosis
268
Q

Bradycardia during a strabismus repair is caused by activation of which cardiac reflex and which afferen and efferent nerves?

A

Oculocardiac
V1 (opthalmic branch)
X

269
Q

In mitral stenosis, the murmur is characterizes as

A

mid-diastolic

270
Q

What are the normal inflections of augmented limb leads

A 
aVR = negative
aVF = postive (greatest)
aVL = positive (less)
271
Q

Mom with HELLP has received a lot of mag. She is now hypotensive, bradycardic and weak. What is wrong and medication should be given?

A

Mag toxicity

Give Calcium = Antidote for Mag toxicity.

272
Q

What is the max dose of mag sulfate?

A

6 mEq/L

273
Q

Patient receives massive blood transfusion, what are some lab changes of Ca++ and K+?

A

hypocalcemia

hyperkalemia

274
Q

What components are in the formed elements?

A

Platelets
Leukocytes
Erythrocytes

275
Q

How does mag sulfate affect mom’s with HELLP? (4)

A

1) Decreases CNS irritability and increases SZ threshold
2) Decreases activity at NMJ and increases weakness
3) Relaxes uterus and smooth muscles and increases uterine BF
4) Treats HTN

276
Q

What is tissue factors action?

A

Activated extrensic factor (III) from injured endothelium

277
Q

When a patient has no active cardiac conditions what are the next surgical considerations when proceeding with noncardiac nonemergent surgery.

A

Is the procedure low risk or high risk?
High risk = proceed to 4
Low risk = proceed with surgery

278
Q

Considerations for tourniquet cases in SCD pts?

A

To decrease peripheral bleeding
Increases risks for peripheral crisis
Monitor time <60 min ideal

279
Q

How is the B-J reflex integrated?

A

Afferent impulses sent via CN X to CV centers of medullar

280
Q

What role dose fibrin-stabilizing factor, serotonin and growth factor play in the plt?

A

Fibrin-stab factor = cross links w/ fibrin

Serotonin = Nearby plt activation

Growth factor = Repair damaged walls

281
Q

Conditions when TXA is contraindicated

A

H/o thrombotic stroke

DIC

282
Q

MI location and artery when leads V3, V4 involved

A

Anterior

LAD

283
Q

What hemostatic medications are contraindicated in DIC?

A

Antifibrinolytics
TXA
Amicar

284
Q

What is the function of antithrombin III?

A

Degrades factors XII, XI, X, IX, II

Anticoagulant

285
Q

Signs of mag toxicity and treatment?

A

1) loss of DTRs
2) Skeletal weakness
3) Hypoventilation
4) Cardiac arrest (low BP, bradycardia)

Treat = give Ca++

286
Q

What are the augmented limb leads and which is most likely used?

A

aVR, aVF, aVL

used = aVF

287
Q

2 drugs that affect inotropy

A

Milrinone

Digitalis

288
Q

Characteristic arterial waveforms for aortic stenosis.

A 
Pulsus parvus (narrow PP)
Pulsus tardus (delayed upstroke)
289
Q

Anterior MI leads, artery, side of heart

A 
Leads = V3, V4
Artery = LAD
Side = Left
290
Q

What would be included in cardiac surveillance for emergent noncardiac surgery?

A

serial ECGs, cardiac enzymes, monitoring

291
Q

FFP may be given with which abnormal lab?

A

Very high PTT

292
Q

Activated clotting time measures the anticoag properties of what medication?

A

Heparin

293
Q

5 types of leukocytes, greatest to least?

A 
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
294
Q

What is normal stroke volume (SV), it’s components and equation.

A

SV = EDV - ESV
End diastolic volume
End systolic volume

50 - 110 ml/beat

295
Q

What is the physiologic response that leads to Cushing’s?

A
  1. Stimulation of cardiac centers of medulla to INC perfusion
  2. INC SNS response
  3. Initially INC HR, BP and contractility
296
Q

Purpose of allen’s test.

A

To test collateral flow in palmar arch

To predict complications associated with radial artery cannulation

297
Q

5 preoperative assessment questions for CAD patients undergoing noncardiac surgery.

A
  1. Consider surgery urgency
  2. Consider active cardiac conditions
  3. Consider risk of surgical procedure
  4. Assess patient’s functionality
  5. Consider patients with poor or indeterminate functional capacity and their comorbidities.
298
Q

Preservative used for blood storage?

A

Citrate phosphate dextrose adenine (CPDA-1)

299
Q

What is vWF?

A

Clotting factor released from injured endothelial cells for platelets to adherence to the injured site.

300
Q

What are endothelial procoagulants?

A

von Wilibrand factor

Tissue factor

301
Q

3 natural fibrinolytics and their function.

A 
Plasminogen = converts to plasmin
tPA = activates plasmin
Urokinase = Activates plasmin
302
Q

In mitral stenosis, increased pulmonary artery occlusive pressure increases the risk of?

A

A-fib

Pulmonary edema

303
Q

What do EKG reciprocal ST changes indicate? What is seen and where?

A

Better confirmation of acute MI

ST depression in reciprocal leads

304
Q

What stimulates the celiac reflex?

A

Traction on the mesentery or the gallbladder causing changes in thoracic and abdominal cavity pressures

305
Q

What ANS response occurs with valsalva?

A

SNS inhibition

PSNS stimulation

306
Q

How long does addition of adenine extend blood storage?

A

21 to 35 days

307
Q

Inspection of CV includes

A

Assess RIJ distention - determine if JVD is present

308
Q

What is hgb in the SCD pt prone to?

A

Hemolysis

Polymerization of hgb S

309
Q

What nerve mediates the valsalva maneuver?

A

Vagus and herring’s nerve from the aortic arch and carotid sinus respectively

310
Q

What is the third phase of plt response?

A

AGGREGATION

311
Q

Leads and artery for anterolateral MI

A 
Leads = V3, V4, V5, V6
Artery = LAD and CIRC
312
Q

Where are platelets located?

A

They run along the vessel walls, not the middle of the vessels

  1. because they are small and pushed aside by large cells
  2. So they are strategically ready if injury is detected
313
Q

Where is NO produced?

A
  • In endothelial cells

- Shear force on endothelial cells stimulates NOS to convert L-arginine into NO

314
Q

What are considered intermediate risk cases and estimated risk of cardiac death or nonfatal MI?

A 
1-5%
Intraperitoneal and intrathoracic surgery
CEAs
Head and neck surgery
Orthopedic surgery
Prostate surgery
315
Q

Where are plts formed?

A

Bone Marrow

By megakaryocytes

316
Q

What is the stimulation for the baroreceptor reflex?

A
  1. Change in arterial flow (inc/dec)

2. Ind/dec stretch of baroreceptors in carotid sinus of aortic arch

317
Q

When do the chemoreceptors respond?

A

PaO2 < 50 mmHg

Acidosis = low pH, hi H+

318
Q

Most common echo finding in pt with SCD

A

Dilated RV

319
Q

Average functional capacity defined as

A

Ability to walk 1-2 glights of stairs or 4 blocks on level surface (MET 5)

320
Q

Decreased O2 supply causes (3) and interventions (6)

A 
Causes = DEC HR/BP, INC PAOP
Interventions
1/2. HR = Anticholinergic, pacing
3/4 BP = vasoconstrictor, DEC anesthetic
5/6. PAOP = NTG, inotrope
321
Q

What are 2 glycoproteins on the plt?

A

GPIb

GPIIb/IIIa

322
Q

Presentation of F V leiden (4) and anesthesia implications?

A

Presentation = Generally found during pregnancy, DVTS, repeated abortions and recurrent fetal loss

Anesthesia implications = high risk for DVT and/or PE
Give anticoagulants

323
Q

What are the components to Cushing’s triad?

A
  1. Hypertension with wide pulse pressure (HI SBP, Lo dbp[for coronary perf])
  2. Reflex bradycardia (prolong diastolic time for coronary perfusion)
  3. Irregular respirations <>
    cheynne-stoke/bradypnea
324
Q

Sickling of the hgb occurs as a result of

A 
LOW PaO2 (hypoxia)
Hypoventilation
Hypothermia
Stress/Pain
Hypovolemia
325
Q

What stimulates the peripheral chemoreceptor reflex?

A

Chemosensitive cells in carotid bodies and aortic arch sense changes to pH and blood O2 content/tension

326
Q

What is the purpose of the vascular phase?

A

To maybe slow down or stop bleeding via vasoconstriction

To keep injury local

Most useful in small injury

327
Q

What is ejection fraction, the equation and normal value

A

Percentage of the end-diastolic volume ejected during systole
EF = EDV-ESV/EDV
EF = SV/EDV
60-70%

328
Q

What lead and wave do you look at for normal axis? QRS direction?

A 
Lead = I and aVF
Wave = QRS POSITIVE
OR
QRS in aVF =positive
QRS in I = positive
329
Q

What is considered a high risk case?

A

Anything above low risk (intermediate and vascular cases)

330
Q

What is the feedback mechanism that regulates BP?

A

SNS response d/t barorecetpor repose
Stimulates RAAS
Release vasopressin (fluid retention)
ALL stimulate vascular smooth muscle and increase SVR w/ Ca++

331
Q

Describe CVP x descent

A

Mid systole
Atrial relaxation
Systolic collapse
ST segment

332
Q

During a stellate ganglion block, the pt becomes tachy and begins to cough. The MOST appropriate intervention is to ____ and why?

A

Get a CXR, to r/o PTX
Lung is inferior to stellate ganglion at C7
Tachycardia and coughing indicate suspicion for PTX

333
Q

Systolic HF treatments for
preload
afterload
contractility

A 
Preload = diuretics if too high
Afterload = SNP
Contractility = dobutamine
334
Q

How is the cardiac index adjusted, what is the equation, and what is the normal value?

A

Adjusted for patient size, their BSA
CI = CO/BSA,
2.8 -4.2 L/min/m2

335
Q

What is the spleens role in plt process?

A
  1. aids in clearance of plts

2. Stores 1/3 of circulating plts for later use

336
Q

Primary hemostasis ends with

A

Platelet plug

337
Q

What are the unipolar leads?

A

aVR, aVF, aVL

338
Q

5 triggers for sickling of hgb

A 
Hypoxia
Hypovolemia
Hypothermia
Stress
Pain
339
Q

What is FFP, how much is in a bag, expiration and dosing?

A 
Fresh Frozen Plasma
Separated from RBC and plt
One bag = 200-250 ml
Expiration = 12 mos
Dose = 10--15 mL/kg
340
Q

What makes up plasma and percentage by volume?

A

Proteins = 7%
Water = 92%
Other solutes = 1 %

341
Q

How much does the fibrinogen level increase with cryo?

A

50 mg/dL

342
Q

What is the normal plt value and lifespan?

A

Value=150k -300k

lifespan = 1-2 weeks

343
Q

Consideration for pts with CAD and 1-2 clinical predictors and =/>3 predictors? What is the risk level?

A

1-2 = intermediate risk
Proceed to OR w/ HR control
Consider noninvasive testing if management will change

=/>3 = higher risk
Consider testing if management will change

344
Q

Explain EKG evidence of poor R wave progression

A
  • Instead of V1-V6 going from more negative S wave to more positive R wave
  • R wave does NOT progressively get positive like it should
  • V6 R wave is not mostly positive
345
Q

Pathophysiology of DIC

A

Systemic activation of coag system simultaneously
Leads to thrombus formation
exhaustion of plt and coag factors

346
Q

What is myocardial injury indicative of?

A

Infarction
Dead tissue
NO O2 supply

347
Q

What is the autoregulation range for coronary blood flow?

A

The coronary vasculature autoregulates between a MAP of 60-140 mmHG

348
Q

What is the intima composition?

A

Endothelial cells

349
Q

Treatment of HELLP?

A

Control HTN
Deliver baby
Stabilize mom by preventing seizures

350
Q

What is a pretreatment option to prevent the bainbridge reflex?

A

Retrobulbar block of CN V1 (opthalmic branch)

351
Q

How many alpha and beta chains are in hgb?

A 
alpha = 2 
beta = 2
352
Q

Describe CVP c wave, cardiac cycle and EKG wave correlation.

A

early systole
Isovolumetric contraction
tricuspid (bulging) motion to RA
R wave

353
Q

What surgeries are considered a low risk case?

A

Superficial or endoscopic
Cataract or breast
Ambulatory

354
Q

How are plts cleared?

A

Macrophages in

  1. reticuloendothelial system
  2. Spleen
355
Q

Citrate binds to?

A

Ca++ aka Factor IV

356
Q

When is a mesh, plt plug formed in hemostasis?

A

Primary phase

357
Q

MI vs Prinzmetal’s angina on 12-lead & treatment?

A

ST elevation for both
CATH clean for Prinzmetals
Treat Prinzmetals w/ CCBs

358
Q

How is HTN control in HELLP syndrome?

A

Mag Sulfate

359
Q

Difference and incidence for primary and secondary HTN

A 
Primary = NO identifiable cause, 95% cases
Secondary = has identifiable cause; 5% cases
360
Q

Coagulation factors are made of what and in what state?

A

Proteins

Inacitve

361
Q

Coumadin MOA?

A

MOA = Vitamin K antagonist, interferes w/ hepatic synthesis of Vit-K dependent factors (F II, VII, IX, X)

362
Q

Lateral MI leads, artery, side of heart

A 
Leads = I, aVL, V5, V6
Artery = Circ (left circumflex)
Heart = Left
363
Q

How does the endothelial layer help with vasodilation or constriction?

A

Releases NO or prostacyclins that act on the adventitia which is primarily smooth muscle

364
Q

6 Indications for plt?

A

1) Thrombocytopenia <10000 w/o bleeding
2) Prophylaxis for LPs, CVC <50,000
3) Bleeding <50,000
4) DIC w/ bleeding<75,000
5) MTPs <75,000
6) Eye/CNS surgery <100,000

365
Q

What is prostacyclin?

A

Lipid molecule produced in endothelial cells (via AracA pathway)

  • POWERFUL VASODILATOR
  • INTERFERES W/ PLT FORMATION AND AGGREGATION
366
Q

How is F VIII concentrate acquired, benefit over cryo, and contains what? When should it be given?

A

Acquired from pool of plasma, large number of donors
Has viral attenuation, decrease infection risk
Contains F VIII and vWF
Give preop and intraop

367
Q

SCD hgb abnormality

A

Beta chain
6th position
Valine (nonpolar) instead of glutamate (polar)
Affects quaternary structure stablity

368
Q

How do you perform the valsalva maneuver?

A

 Off vent – go to manual mode
 ↑APL (adjustable pressure limiting
• ↑ to 30 mmHg
 Press bag to ↑ intrathoracic pressure

369
Q

What are the components of ejection fraction

A

End diastolic volume EDV

End systolic volume ESV

370
Q

Indications for cryoprecipitate? (4)

A

LOW fibrinogen (factor I)

1) Microvascular bleeding w/ LOW fibrinogenemia
2) DIC w/ fibrinogen<80-100 mg/dL
3) Hemorrhage or MT w/ fibrinogen <100-150 mg/dL
4) Prophylaxis in hemophelia A, vWD, or congenital dysfibrinogenemias

371
Q

Purpose of endothelin in vasoactive phase.

A

Stimulates smooth muscle contraction
Stimulates cell division of endothelial cells, smooth muscle cells, fibroblasts
Aids repair of damaged sites

372
Q

Causes of right HF and treatment

A 
Causes = INC PVR that impairs RV fxn b/c right heart is thinner and more compliant
Treatment= inotropes, DEC PVR, NO donors
373
Q

What are some treatments for cardiac reflex?

A

Anticholinergic (glycopyrolate, atropine)

Decrease insuflation

374
Q

5 Postulated mechanisms of primary HTN

A

1) Chronic vasoconstriction activating RAAS and fluid retention
2) SNS over-activity leads to chronic vasoconstriction and INC SVR
3) Vasodilatory deficiency (low NO, PGs)
4) Collagen/protein deposition in arterial intima = stiff
5) High Na+ diet intake

375
Q

What is vaso-occlusive crisis (VOC), how does it manifest, what is the periop incidence and how is it treated?

A 
Most frequent manifestation
D/T tissue ischemia or infarction
Causes mild to severe pain
Incidence = 10%
Treat 
Mild pain = PO analgesics, hydration
Severe pain = hospitalization, IV narcotics, IV hydration, O2
376
Q

After blood is removed from cold storage, max time to be given and why?

A

Less than 30 minutes

Longer time promotes bacterial growth

377
Q

What factors can decrease O2 fraction?

A

LEFT shift in Oxyhgb dissociation curve

Decreased capillary density

378
Q

What is the drawback to cryoprecipitate preparation?

A

Not submitted to viral attenuation

Poses increased risk of infection

379
Q

When proceeding with noncardiac emergency surgery, what should be the cardiac focus?

A

Focus on perioperative surveillance and risk reduction

380
Q

How can the bainbridge reflex be blunted?

A

Release of stimulus

Give anticholinergic like glycopyrolate (vagalytic)

381
Q

Where do clotting factors hang out?

A

Endothelial cells of the intima layer of vessels

382
Q

What is the role of fibronectin in hemostasis?

A

Facilitates anchoring of fibrin during formation of hemostatic plug

383
Q

Prostacyclins cause vessels to do what?

A

Vasodilate

384
Q

What is the first phase of plt activation?

A

ADHERENCE

385
Q

What is platelet aggregation?

A
  • The release of mediators following plt metamorphosis

- To prompt plts to form primary PLT PLUG

386
Q

What are 4 cardiac demand variables

A

Heart rate
Preload
Afterload
Contractility

387
Q

List the types of vWF disorder from most most treatable to least. Also indicates severity.

A 
Type 1
Type 2A
Type 2M
Type 2B
Type 2N
Type 3
388
Q

EKG diagnostic criteria for left atrial hypertrophy

A 
Terminal portion of diphasic P wave 
--  LARGER, >1 small box
OR
Diphasic P wave
--  >120 ms (3 small boxes)
389
Q

What are bipolar leads and their normal inflections?

A

Leads with both positive & negative
Leads I, II, III
Normally positive

390
Q

Purpose of the media layer in the vessel

A

Extremely active thrombogenic middle layer

391
Q

Effects of mag sulfate on CNS and NMJ.

A

CNS decrease irritability– increase Sz threshold

NMJ decrease activity– may cause weakness

392
Q

Hemoptysis after PA cath insertion is indicative of?

A

PA rupture

Assessment (3 decks)

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