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Anesthesia & Coexisting Disease > Ex2 Pericardial Dx > Flashcards

Ex2 Pericardial Dx Flashcards

1
Q

Hallmark sign: Pericarditis

A

chest pain - worsens with deep breath, relieved when sitting forward

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2
Q

Auscultation of pericarditis

A

friction rub

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3
Q

pericarditis ECG changes

A

occurs 90% of time
Stage I: ST segment elevation, PR segment depr.
Stage III: T wave inversion

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4
Q

Causes of Pericarditis

A

Infective
1-2d post MI
Dresslers syndrome (autoimmune)
Penetrating trauma, PPM, metastatic dx, systemic dx

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5
Q

Dresslers syndrome

A

post MI - necrotic myocardium tissue enters circulation + acts like antigen

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6
Q

Pericarditis Tx

A

Salicyclates, other NSAIDs
ASA or Ketorolac
Symptomatic relief: codeine (esp helpful if + cough)
Steroids: reserved for refractory cases (assoc. pericardial relapse)

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7
Q

accumulation of fluid surrounding heart

A

pericardial effusion

fluid in pericardial sac

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8
Q

Normal volume in pericardial sac vs. pericardial effusion

A

norm=5-50
effusion > 100mL
(up to 2L if chronic)

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9
Q

pressure of pericardial fluid impairs cardiac filling

A

cardiac tamponade

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10
Q

types of pericardial effusion

A

atraumatic (serosanguinous/exudative) - neoplasm

traumatic (blood)

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11
Q

S/S cardiac tamponade

A

Ventricular discordance
Becks triad
Increased CVP

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12
Q

Becks Triad

A
  • distant heart sounds
  • increased JVP
  • hypotension
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13
Q

Ventricular discordance

A

Pulsus Paradoxus

Kussmauls sign

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14
Q

Kussmauls sign

A

JVD during inspiration

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15
Q

Pulsus Paradoxus

A

Decr. SBP 10 mmHg during inspiration
(impairment of diastolic filling of LV)
*present in 75% of acute cases

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16
Q

S/S chronic tamponade

A

Tachycardia, JVD, hepatomegaly, peripheral edema, increased CVP

17
Q

How to determine pulsus paradoxus?

A

RR + ABP on monitor - correlate

18
Q

Hemodynamic occurrence in chronic cardiac tamponade

A

LAP = RVEDP

19
Q

Gold standard for Cardiac Tamponade

A

Echocardiography

20
Q

CXR - cardiac tamponade

A

“water bottle heart”

21
Q

Definitive diagnosis of cardiac tamponade

A

R-sided heart cath

22
Q

Right Sided Heart Cath shows what in cardiac tamponade?

A
  • pressures within cardiac chambers eventually equilibrate.
  • confirmed by R-sided heart catheterization.
  • PAOP and PADP (both estimates of LA pressure and LVEDP), RAP, and RVEDP will be =
23
Q

Tamponade Tx

A
  • Expand intravascular volume
  • isoproterenol - increase contractility/HR
  • dopamine - increase SVR
  • correct metabolic acidosis
  • monitor CVP, Aline
  • pericardiocentesis or pericardiostomy
24
Q

What is the anesthetic of choice for pericardiocentesis in a hypotensive patient?

A

Local anesthetic

*GA = need to resuscitate

25
Q

Goals of induction/maintenance in pt with cardiac tamponade?

A

Maintain CO/BP

26
Q

What HD changes may occur after pericardiocentesis?

A

HTN, arrhythmia

Have crash cart nearby + people to help

27
Q

fibrous scarring, adhesions that obliterate pericardial space

A

chronic constrictive pericarditis

rigid shell around heart - not allowing to beat effectively

28
Q

Causes of chronic constrictive pericarditis

A

idiopathic - TB/viral/connective tissue dx

previous cardiac surgery, acute

29
Q

s/s chronic constrictive pericarditis

A

increased CVP + low CO

  • no other s/s Heart dx
  • vague symptoms: decreased METs/fatigue
30
Q

diagnosis chronic constrictive pericarditis

A

echo - normal wall motion with pericardial thickening

31
Q

Tx chronic constrictive pericarditis

A

“Cardiac Stripping”

-surgical removal of constricting pericardium

32
Q

What HD changes may occur after cardiac stripping?

A

Slow HD improvement (over 3 months)

-may be d/t atrophy of myocardial fibers, persistent restrictive effects of pericardium

33
Q

Anesthetic management - Cardiac Stripping

A

Minimize changes in: HR, SVR, venous return, myocardial contractility
*benzo +/- opioids
optimize pre-op intravasc. volume
long case - fluid shifts, blood loss
Aline + CVP
Dysrhythmias = common *have defibrillator nearby

34
Q

What aspects of the induction of general anesthesia would have detrimental effects on the patient with cardiac tamponade? select 2
A. Peripheral vasodilation from administration of an inhaled anesthetic
B. Hypertension due to laryngoscopy
C. Increased heart rate during laryngoscopy
D. Positive pressure ventilation

A

A/D
- The combination of peripheral vasodilation and myocardial depression from the anesthetic and decreased venous return from positive pressure ventilation can produce severe, life-threatening hypotension in the patient with cardiac tamponade.

35
Q

Which of the following interventions would be appropriate in the management of a patient with symptomatic cardiac tamponade until a pericardiocentesis can be performed? (select four)
A. Administering a colloid solution intravenously
B. Administering a crystalloid solution intravenously
C. Administration of beta blocker to prevent tachycardia
D. Administration of isoproterenol to prevent bradycardia
E. Administration of atropine to prevent vagal reflexes
F. Hypoventilate to create mild to moderate acidosis
G. Administer nitroglycerin to decrease SVR
H. Performing carotid massage as a temporizing measure

A

ABDE
The primary goals in the management of a patient with symptomatic cardiac tamponade include: expanding intravascular volume by administering crystalloids or colloids, maintaining heart rate and contractility by administering catecholamines (including isoproterenol), administering dopamine to increase systemic vascular resistance if necessary, administering atropine to prevent vagal reactions to the increased intrapericardial pressure, and correcting metabolic acidosis (metabolic acidosis can have detrimental effects on cardiac contractility).

36
Q

What induction agent is most useful for the patient with cardiac tamponade undergoing general anesthesia?

A

Induction is typically carried out with ketamine because it increases heart rate, contractility, and systemic vascular resistance. A benzodiazepine is often combined with it. The anesthetic may be maintained with nitrous oxide and fentanyl combined with pancuronium, which is useful for its vagolytic effects.

37
Q

Which of the following statements regarding pericarditis is not true
A. It produces myocardial depression
B. It is often relieved by sitting forward
C. It initially produces diffuse ST segment elevation
D. It is commonly preceded by a viral infection

A

A
Pericarditis is often due to a viral illness, but may often occur 1-3 days after a myocardial infarction. Deep inspiration worsens the pain. It is often relieved by sitting forward. The ECG changes seen in acute pericarditis occur in four stages. In stage I, there is diffuse ST segment elevation and depression of the PR segment. In stage 2, the ST and PR changes normalize. In stage 3, the T wave inverts, and in stage 4, the T waves normalize. If no other associated pericardial disease is present, acute pericarditis does not alter cardiac function.

38
Q

Which of the following symptoms of cardiac tamponade are indications of ventricular discordance? (select two)
A. Beck’s triad
B. Kussmaul’s sign
C. Decreased voltage on the electrocardiogram
D. Pulsus paradoxus

A

BD
Kussmaul’s sign and pulsus paradoxus are both indicative of ventricular discordance (also known as ventricular dyssynchrony) that occurs due to the opposing response of the ventricles to filling during the respiratory cycle.

Anesthesia & Coexisting Disease (23 decks)

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