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Cardiovascular Anesthesia > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

What is the most superficial layer of the pericardium?

A

fibrous pericardium

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2
Q

What is the most interior layer of the pericardium?

A

visceral pericardium

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3
Q

Pericardial fluid lies between which two layers of the pericardium?

A

parietal and visceral layer of serous pericardium

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4
Q

What happens to intracardiac pressure with acute increase in pericardial fluid?

A

CVP, PAD, and PAOP equalize and increase

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5
Q

What are causes of acute increased pericardial fluid?

A

1 tamponade dissection

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6
Q

What are causes of chronic increases in pericardial pressure

A

pericarditis

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7
Q

How does chronic increase in pericardial pressure change intrathoracic pressure.

A

Overtime cardiac sac stretches and pressures equalize

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8
Q

What do gap junctions facilitate?

A

conduction of the action potential from one cell to another

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9
Q

Why are there large amounts of mitochondria in the myocardium?

A

Lots of ATP is needed for the constant contraction of myocardium and high energy demands.

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10
Q

What structures of the myocardium allow for rapid release and reabsorption of Ca?

A

T-tubular system and sarcoplasmic reticulum

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11
Q

What is used treat hyperkalemia to raise the threshold potential and decrease arrhythmia?

A

Calcium

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12
Q

What separates the atria and ventricles?

A

coronary sulcus

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13
Q

what separates the RV and LV and descends from the coronary sulcus to the apex?

A

Interventricular sulci

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14
Q

Where do the coronary and posterior interventricular sulci meet?

A

Crux

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15
Q

What blood vessel lies in the anterior inter ventricular sulci?

A

LAD

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16
Q

What blood vessel drains the myocardium?

A

coronary sinus, O2 poor

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17
Q

Describe the anterior and posterior walls of the RA?

A

trabeculated anterior smooth posterior

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18
Q

What does the moderator band of the trabeculae carneae in the RV carry?

A

right branch of the AV bundle

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19
Q

What chamber of the heart provides 20-30% of LVEDV? “atrial kick’

A

LA

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20
Q

Does the LA receive blood from pulmonary arteries or veins?

A

veins

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21
Q

Where are clots likely to form in the LA?

A

atrial appendage

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22
Q

The majority of the LV septum is covered with…?

A

trabeculae carneae

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23
Q

Where is the tricuspid valve

A

between the RA and RV

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24
Q

Where is the mitral valve?

A

between the LV and LA

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25
Q

What is the normal area of the tricuspid valve?

A

7cm

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26
Q

Symptoms of tricuspid stenosis occur when the valve is?

A

< 1.5cm

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27
Q

Label the leaflets of the tricuspid valve.

A
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28
Q

What are the three leaflets of the tricuspid?

A

anterior, septal, and posterior

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29
Q

what is the normal area of the mitral valve?

A

4-6cm

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30
Q

what are the two leaflets of the mitral valve?

A

Anteromedial leaflet Posterolateral leaflet

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31
Q

Label the leafets of the mitral valve

A
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32
Q

When do symptoms of mitral stenosis appear?

A

valve area decreased by half, 2-3cm

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33
Q

What valve is the gateway to the body?

A

aortic valve

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34
Q

what is the normal area of the aortic valve?

A

2.5-3.5 cm

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35
Q

what are the cusps of the aortic valve?

A

Right coronary cusps Left coronary cusps Noncoronary cusps

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36
Q

what are the locations of the aortic cusps?

A

right is 11-3, non coronary is 3-7, left coronary is 7-11

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37
Q

When do symptoms of aortic disease appear?

A

Reduction of area by 1/3 to 1/2

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38
Q

What is the Keith Flack node?

A

the SA node

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39
Q

What part of the conduction system is located along the EPICARDIAL surface at the junction of the SVC and RA

A

SA node (Keith flack)

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40
Q

What are the two cell types of the SA node?

A

pacemaker and transitional

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41
Q

Which SA node cells initiate an action potential and which propagates the action potential?

A

pacemaker initiate transitional propagate

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42
Q

what is the intrinsic rate of the SA node>

A

60-100

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43
Q

What artery supplies the SA node?

A

PDA

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44
Q

Which internodal tract is called bachmans bundle?

A

anterior internodal

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45
Q

Where does the anterior internodal (bachmanns) tract transmit the signal from the SA node?

A

sends fibers to the LA and then travels down through the atrial septum to the AV node

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46
Q

Which internodal tract is called wenckebach tract?

A

middle internodal tract

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47
Q

Where does the middle internodal (wenckebach) tract transmit the signal from the SA node?

A

curves behind the SVC before descending to the AV node

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48
Q

Which internodal tract is called thorel tract?

A

posterior internodal tract

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49
Q

Where does the posterior internodal (thorel) tract transmit the signal from the SA node?

A

continues along the terminal crest to enter the atrial septum and then passes to the AV node

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50
Q

Which part of the conduction system is located beneath the ENDOCARDIUM on the right side of the atrial septum, anterior to the opening of the coronary sinus

A

AV node

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51
Q

The AV node is able to slow the action potential because theses cells make up the AV node.

A

vagal cells

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52
Q

what is the intrinsic firing rate of the AV node?

A

40-55

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53
Q

What is the other name for the AV bundle?

A

bundle of his

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54
Q

Where does the AV bundle transmit signals?

A

Extends from the lower end of the AV node and enters the posterior aspect of the ventricle and the Purkinje system

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55
Q

What is the preferential channel for conduction of the action potential from atrium to ventricles?

A

AV bundle

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56
Q

what is the intrinsic firing rate the AV bundle?

A

25-40

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57
Q

Ischemia of the anterolateral wall, posterior ventricular wall, and anterior papillary muscle would affect which purkinje fascicle?

A

anterior fascicle of the Left bundle branch

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58
Q

Ischemia to the lateral and posterior ventricular wall and the posterior papillary muscle would affect with purkinje fascicle?

A

posterior fascicle of the left bundle branch?

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59
Q

where does the right bundle branch of the purkinje system travel?

A

under the endocardium along the right side of the ventricular septum to the base of the anterior papillary muscle

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60
Q

What is the intrinsic firing rate of the purkinje system?

A

25-40

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61
Q

What is the most common PRE-EXCITATION syndrome?

A

WPW

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62
Q

What are EKG findings of WPW?

A

DELTA WAVE Short PR Wide QRS

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63
Q

Describe orthodromic AVNRT?

A

more common Narrow QRS

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64
Q

How do you treat orthodromic AVNRT?

A

block AV node with: Amiodarone Cardioversion Vagal maneuveur adenosine BB verapamil

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65
Q

Describe antidromic AVNRT?

A

more dangerous Wide QRS

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66
Q

How do you treat antidromic AVNRT?

A

block accessory pathway Amiodarone Cardioverison Procainamide

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67
Q

Where are K, Cl, and Na most abundant?

A

K inside Na, Cl outside

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68
Q

What ion is responsible for RMP?

A

Potassium

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69
Q

Is the Na/K pump active or passive?

A

Active, requires ATP.

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70
Q

What electrolytes are responsible for the ventricular action potential?

A

phase 0: Na phase 1: K, Cl phase 2, Ca, K phase 3: K Phase 4: Na/K ATPase

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71
Q

Why does hyperkalemia increase RMP?

A

potassium doesnt leak out of the cell, lack of gradient

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72
Q

What describes absolute refractory period?

A

Phase 0-3 lasts until membrane potential drops below -60mV

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73
Q

What describes relative refractory period?

A

middle of phase 3 to beginning of phase 4 -60mV to -90mV

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74
Q

What causes the SA node to have a higher resting membrane potential?

A

more permeable to Na

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75
Q

What electrolytes are responsible for the SA node action potential?

A

Phase 4: Na, Ca (t-type) Phase 0: Ca (l-type) Phase 3: K

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76
Q

What determines HR?

A

rate of spontaneous phase 4 depolarization

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77
Q

What catecholamines change phase 4 depolarization?

A

Epi, NE increase acetylcholine decreases

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78
Q

what is the volume of coronary blood flow?

A

225-250mL/min, 4-7% CO

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79
Q

Autoregulation of coronary blood flow is maintained between what values?

A

60-140

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80
Q

What happens when the MAP is outside autoregulatory range?

A

pressure dependent

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81
Q

what is myocardial oxygen extraction ratio?

A

70%

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82
Q

When does coronary filling take place?

A

diastole

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83
Q

How does increased HR affect coronary blood flow?

A

decreases filling time and decrease supply

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84
Q

What are the main branches of the left main?

A

LAD and Circumflex

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85
Q

What does the LAD supply?

A

1st Diagnal 1st septal perforator

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86
Q

What does the circumflex supply?

A

Sinus node artery (40-50% of the population) Left atrial circumflex artery Anterolateral marginal artery Distal circumflex artery Posterolateral marginal artery PDA (10-15% of the population)

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87
Q

What parts of the heart does the LAD supply?

A

anterior 2/3 of inter ventricular septum L bundle branches anterior LV

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88
Q

What vessel provides blood flow to the lateral LV?

A

Circumflex

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89
Q

What does the right main supply?

A

Conus artery Sinus node artery (50-60% of the population) Anterior right ventricular branches Right atrial branches Acute marginal branches AV node artery (90%) Proximal bundle branches PDA (most common) Terminal branches

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90
Q

What parts of the heart does the RCA supply?

A

SA node (80%) Right atrium Right ventricle Posterior 1/3 of the interventricular septum Inferior LV

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91
Q

What determines coronary artery dominance?

A

which blood vessel supplies the PDA

92
Q

What rhythm would you expect to see with an occluded dominant artery?

A

CHB, ST elevation

93
Q

Where does the coronary sinus drain?

A

RA

94
Q

Rate of blood flow within a vessel is determined by what?

A

change in pressure within the vessel/resistance

95
Q

How is Coronary perfusion pressure calculated?

A

AoDBP - LVEDP

96
Q

What happens to blood flow to the subendocardium during systole?

A

decreases

97
Q

What intrinsic factors affect coronary artery tone?

A

anatomic arrangement and perfusion pressure

98
Q

what extrinsic factors affect coronary artery tone?

A

compressive factors, w/in myocardium, metabolic, neural and humoral

99
Q

Coronary blood flow is mainly determined by what two factors?

A

O2 supply and demand

100
Q

How do we increase O2 delivery?

A

increase blood flow

101
Q

what is the biggest determinant of myocardial O2 supply and demand?

A

Heart rate

102
Q

What affects myocardial O2 supply? (4)

A

coronary artery anatomy diastolic pressure diastolic time (HR) O2 extraction (Hgb, SaO2)

103
Q

What affects O2 demands?

A

HR preload (wall stress) afterload contractility

104
Q

What vasodilators released by the myocardium increase coronary flow 3-4x? (7)

A

Adenosine NO PGE H+ CO2 Bradykinin K+

105
Q

How does O2 affect coronary vascular resistance??

A

increases resistance

106
Q

How is CaO2 calculated?

A

(Hgb x 1.36 x SpO2) + (0.003 x PaO2)

107
Q

How is DO2 calculated?

A

CO x [(Hgb x 1.36 x SpO2) + (0.003 x PaO2) x 10]

108
Q

What is normal CaO2?

A

20

109
Q

What is normal DO2?

A

1000

110
Q

What are the bipolar leads of an EKG?

A

I, II, III (+ and - electrode)

111
Q

What are the unipolar leads of an EKG?

A

aVR, aVL, AVF (+ electrode)

112
Q

What are the 6 precordial leads?

A

V1-V5 (horizontal plane)

113
Q

Explain the R wave progression (from negative deflection to positive deflection) of the precordial leads?

A

Due to placement Electrical activity is moving away from V1 and V2 (negative deflection), V3 neutral, V4-V5 positive deflection (towards electrode)

114
Q

What leads monitor the interventricular septum?

A

V1, V2

115
Q

What leads monitor the inferior wall?

A

II, III, aVF

116
Q

What leads monitor the anterior wall?

A

V3, V4

117
Q

What leads monitor the anterolateral wall?

A
118
Q

What leads monitor the lateral wall?

A

I, aVL, aVR

119
Q

Leads II, III, and aVF monitor ischemia of which coronary artery?

A

RCA

120
Q

Leads I, aVL, V5, V6 monitor for ischemia of which coronary artery?

A

Circ

121
Q

Leads V3, V4 monitor for ischemia of which coronary artery?

A

LAD

122
Q

The anterior wall is fed by which coronary artery?

A

LAD

123
Q

The inferior wall is fed by which coronary artery?

A

RCA

124
Q

The lateral wall is fed by which coronary artery?

A

Circ

125
Q

What leads determine axis deviation?

A

I, aVF

126
Q

What is the axis deviation of a postitive deflection of lead I and postive in lead aVF?

A

Normal

127
Q

What is the axis deviation of a postitive deflection of lead I and negative on lead aVF?

A

Left axis deviation

128
Q

What is the axis deviation of a negative deflection of lead I and postive on lead aVF?

A

Right axis deviation

129
Q

What is the axis deviation of a negative deflection of lead I and negative on lead aVF?

A

Extreme right axis

130
Q

What helps determine axis deviation?

A

Negative deflection points to deviation side

131
Q

How do vectors point to hypertrophied and infarcted myocardium?

A

point towards hypertrophied myocardium

point away from infarcted myocardium

132
Q

What causes Right axis deviation?

A

COPD, acute bronchospasm, cor pulmonale, P. HTN, P. elmbolus

133
Q

What causes Left axis deviation? (5)

A

chronic HTN, LBBB, AoV stenosis, AoV regurgitation, MV regurg

134
Q

For left axis deviation think…

A

Pressure

135
Q

For right axis deviation think…

A

Lung disease

136
Q

what is the normal direction of depolarization of interventricular septum

A

left to right

137
Q

what causes the R’ wave in RBBB?

A

RV has a delayed depolarization

138
Q

Describe depolariation in LBBB?

A

RV depolarizes before the LV

downward deflection wide S wave (very small R wave)

139
Q

Which BBB will have a wide QRS?

A

LBBB

140
Q

What causes a LBBB?

A

MI, cardiomyopathy, myocarditis, HTN

141
Q

What causes a RBBB?

A

congentital, PE, Pulm. HTN, Myocarditis, MI, age

142
Q

Whichi BBB is more concerning and which is more benign?

A

LBBB more concerning

RBBB benign

143
Q

What leads do you look for a BBB?

A

V1

QRS longer than 0.12 (3 small boxes)

144
Q

whats the formula for CO?

A

HR x SV

145
Q

What determines SV? (3)

A

preload, afterload, contractility

146
Q

What estimates preload of the LV?

A

CVP

147
Q

How is afterload calculated?

A

SVR =( (MAP-CVP)/ CO ) x 80

148
Q

Contractility is independent of what?

A

preload and afterload

149
Q

What is the formula for Cardiac output?

A

HR x SV

150
Q

What is the formula for CI?

A

CO / BSA

151
Q

What is the formula for MAP?

A

(SBP + 2DBP) / 3

152
Q

What is the formula for Stroke volume?

A

CO x (1000x HR)

EDV-ESV

153
Q

What is the formula for SVI?

A

SVR / BSA

154
Q

What is the formula for SVR?

A

[(MAP-CVP) / CO] x 80

155
Q

What is the formula for PVR?

A

[(MPAP - PCWP) / CO] x 80

156
Q

What is the formula for EF?

A

(SV/EDV) x 100

157
Q

What reflex is forced expiration against a closed glottis?

A

Valsalva

158
Q

What are the afferent nerves of the valsava refelx?

A

Herings, CN 9, CN 10

159
Q

What is the control center of the valsalva refelx?

A

vasomotor center in the medulla

160
Q

What is the response of the valsalva reflex?

A

Inhibit SNS, stimulate PNS

decrease HR, contractility, BP

161
Q

Hypotension during induction would activate which reflex?

A

baroreceptor

162
Q

Where are mediators of the baroreceptor reflex located?

A

stretch receptors in the carotid sinus and aortic arch

163
Q

What is the baroreceptors response to HTN and HoTN?

A

HTN -> decreased HR, BP

164
Q

Describe the occulocardiac reflex.

A

5 and dime reflex): traction on the extraocular muscles (media rectus), conjunctiva, or orbital structures results in decreased BP, HR and arrythmias

165
Q

What is the afferent pathway of the oculocardiac reflex?

A

long/short ciliar nerves of CN 3 -> CN 5 -> gasserian ganglion

166
Q

What is the celiac reflex?

A

traction on the mesentery or the gallbladder or stimulation of the vagus nerve in other areas of the body

167
Q

What are symtpoms of the celiac relfex?

A

bradycardia, apnea, hypotension

168
Q

What is the stimulus of the brainbridge reflex

A

increased volume of blood in the heart leading to SNS stimulation

169
Q

What are the sensors of the bainbridge reflex?

A

stretch receptors in RA, VC, and pulmonary veins

170
Q

What are the afferent, control center, and efferent pathways of the bainbridge reflex?

A

Afferent: vagus

Control: medulla

Efferent: vagus

171
Q

What relfex is activated when the heart is empty?

A

Bezold-Jarisch

172
Q

What is the stimulus for the BJ reflex?

A

low venous return or MI

173
Q

What is the afferent, control and response of the BJ reflex?

A

Afferent: vagus

control: medulla

Response: decrease HR, BP, coronary vasodilation

174
Q

What are potential causes of a wide pulse pressure on A-line?

A

Aortic regurg, hypovolemia, sepsis

175
Q

What are potential causes of a narrow pulse pressure on A-line

A

AS

tamponade

176
Q

What does the location of the dicrotic notch on A-line tell you?

A

High: high SVR

Low: vasodilated

177
Q

Where is closure of the aortic valve represented on the A-line tracing?

A

Dicrotic notch

178
Q

What does systolic upstroke demonstrate on A-line?

A

ventricular ejection

179
Q

What does a steep systolic upstroke tell you?

gradual upstroke?

A

steep: vasodilated
gradual: stenosis

180
Q

What causes pulsus tardus et parvus?

A

conditions that decrease SV

narrow pulse pressure

elevated SVR

181
Q

What valve lesion causes pulsus tardus et parvus?

A

aortic stenosis

182
Q

What happens to arterial line waveform morphology as you move away from the aortic root?

A

SBP increases

DBP decreases

MAP constant

Pulse pressure widens

183
Q

If the patient has three arterial lines one in the brachial artery, femoral artery and dorsalis pedis. Which waveform would have the highest peak systolic pressure?

A

DP

184
Q

What causes the dicrotic notch on the A-line?

A

closure of the Aovalve

185
Q

When are the coronary arteries perfused?

A

diastolic run-off

186
Q

How does vasodilation and vasocontriction affect the time it takes to get to end-distolic pressure?

A

vasodilation will cause a steep decline (reach DBP sooner)

vasoconstriction will cause a gradual decline in DBP (reach DBP slower)

187
Q

Which internal jugular vein has the higher risk for lacteration of the brachiocephalic vein or SVC?

A

left

188
Q

Where should the IJ catheter lie?

A

above the junction of the SVC and RA

189
Q

What are the postitive deflection and negative deflections of a CVP waveform?

A

positive: A, C, V

negative X, Y

190
Q

On the CVP waveform which deflections occur during diastole and systole?

A

systole: C, X, Y

Diastole: A, Y

191
Q

What do each of the CVP waveforms represent?

A

A- Atrial contraction

C- tricuspid elevation into the RA

X- downward movement of the contracting RV

V- back pressure from blood filling the RA

Y- tricuspid opens in early V. diastole

192
Q

What is CVP a function of?

A

intravascular volume, venous tone, RV compliance

193
Q

What conditions cause a high CVP?

A

hypervolemia, RV failure, TV stenosis or regurg, pulm stenosis, pulm HTN, PEEP, VSD, constrictive pericarditis, tamponade

194
Q

what conditions lower CVP?

A

hypovolemia

195
Q

What zone of the lung gives accurate PA pressures? Why?

A

Zone 3

continuous column of blood flow b/w the PAC and LV

Pa > Pv > PA

196
Q

What are the zones of the lungs and describe the pressure differences between the zones?

A

Zone I = Dead Space : PA>Pa>Pv

Zone II = Waterfall: Pa > PA > Pv

Zone III = Pa > Pv > PA

197
Q

what are contraindications for a PAC?

A

RBBB, TV disease, Right mass, mechanical Pulmonary valve

198
Q

What BBB is a contraindication to PAC?

A

LBBB, causes a RBBB -> CHB

199
Q

What are the waveforms of the PCWP?

A

A wave: atrial contraction

C wave: closure/bulge of MV d/t LV systole (isovolumetric contraction)

X descent: atrial distole

V wave: passive atrial filling

Y descent: passive atrial empyting

200
Q

What are the distances for central line placement?

A
201
Q

What causes loss of an A wave?

A

a fib, V pacing

202
Q

What causes large A waves?

A

TV/MV stenosis

Diastolic dysfunction

MI

ventricular hypertrophy

AV dissociation

Junctional rhythm

PVC

CHB

203
Q

What cause large V waves?

A

Tricuspid/Mitral regurg, acute intravascular volume increase, RV papillary muscle ischemia

204
Q

Label the Waves.

A
205
Q

When does PWP overestimate LVEDV?

A

MR, MS, increased intrathoracic pressure, pulm HTN, not in zone 3

206
Q

When does PCWP underestimate LVEDV?

A

Chronic Aortic Insufficiency

RBBB

207
Q

What is the assumption made with PAC regarding pressures?

A

CVP = PADP = PAOP = LAP = LVEDP = LVEDV

208
Q

When does CVP not equal PADP

A

Change in RV compliance

Tricuspid valve disease

209
Q

When does PADP not equal PAOP?

A

Pulmonary HTN

MR or AR

Lung zone I or II

Tachycardia

ARDS

RBBB

210
Q

When does PAOP not equal LAP?

A

Juxtacardiac pressure (PEEP)

Lung zone I or II

Mediastinal fibrosis

RBBB

211
Q

when does LAP not equal LVEVP?

A

Juxtacardiac pressure (PEEP)

Mitral valve disease

Change in LV compliance

212
Q

When does LVEDP not equal LVEDV?

A

PEEP

v. interdependence

Change in LV comliance

213
Q

What determines SvO2?

A

Pulmonary function (SaO2)

Cardiac function (CO = Q)

Oxygen delivery

Tissue perfusion

Oxygen consumption (VO2 = 250ml/min)

Hemoglobin concentration (Hgb)

214
Q

What is the equation for SvO2?

A

SvO2 = SaO2 – (VO2/(Q x 1.34 x Hgb) x 10)

215
Q

What decreases SvO2?

A

increased O2 consumption (stress, pain , thyroid storm, shivering, fever) and decreased O2 delivery

216
Q

What increases SvO2?

A

decreased consumption: hypothermia, cyanide toxicity

increased delivery: increased PaO2, increased Hgb, increased CO

217
Q

How do you treat SvO2?

A
218
Q

With aortic stenosis you would expect to see what derangement on the arterial waveform?

Wide pulse pressure

Lower dicrotic notch

Steep slope of the systolic upstroke

narrow pulse pressure

A

(narrow) pulse pressure
(higher) dicrotic notch
(gradual) slope of the systolic upstroke

narrow pulse pressure

219
Q

The area under the curve correlates with what:

SBP

DBP

MAP

SVR

A

MAP

220
Q

What happens to the tracing as you move further from the ascending aorta?

Decrease in SBP

Increase in DBP

Narrowed pulse pressure

No change to MAP

A

(increase) in SBP
(decrease) in DBP
(wide) pulse pressure

No change to MAP

221
Q

What is the A wave associated with in the CVP waveform?

Ventricular contraction

Passive atrial filling

Atrial contraction

ventricular emptying

A

Atrial contraction

222
Q

What would cause a cannon A wave on a PAC tracing?

Mitral stenosis

Tricuspid stenosis

A-fib

Tricuspid regurgitation

Mitral regurgitation

A

Mitral stenosis

223
Q

How many cm would you expect to insert a central line when using the RIJ?

10

15

20

25

A

15

224
Q

A patient present with acute RV failure with a PAP of 62/25, HR 74, BP 88/40, CI 1.8. What combination of drugs would be a drug to treat this patient with?

Norepinephrine

Phenylephrine

vasopressin

Milrinone

Epinephrine

A

Vasopressin

Milrinone

225
Q

During your preop assessment, you notice this on the ECG? The patient is scheduled for a AVR and the surgeon is asking for a PAC. What do you do?

A

No PAC, LBBB increases the chance of RBBB and CHB

226
Q

During insertion of the PAC notice this on the ECG. What should you do?

Monitor closely as you continue to thread PAC

Withdraw PAC immediately

Ignore as it must be from the techs prepping the patient

Give lidocaine

A

monitor closely as you thread the PAC

Cardiovascular Anesthesia (4 decks)

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