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Mar: Sem 4 - Principles II > Exam 1: Cardiac Monitoring > Flashcards

Exam 1: Cardiac Monitoring Flashcards

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1
Q

What is shown on this EKG?

A

Right BBB (use the “turn signal” method on V1 only)

S9

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2
Q

What is shown on this EKG?

A

Left BBB (“turn signal” goes down)

S10

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3
Q

What is indicated by the pink highlighted portion of the P wave below?

A

Right Atrial Hypertrophy
- Initial component of P is larger in V1
- Height is > 2.5mm in any limb lead

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4
Q

What is indicated by the blue highlighted portion of the P wave below?

A

Left Atrial Hypertrophy
- Terminal portion of diphasic P in V1 is larger
- occurs with mitral stenosis and systemic HTN

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5
Q

P-waves for lead II and Lead VI are shown below. What would be indicated by this EKG waveform?

A

Bi-atrial enlargement

S12

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6
Q

What is indicated in this EKG?

A

RV Hypertrophy
- RV wall is thick therefore we have more depolarization toward V1
- QRS in V1 positive - R waves get smaller

not on the slide: but we also see more negative deflection in lead I - indicating the current travels more right

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7
Q

What is this EKG showing?

A

LV hypertrophy
- Large S wave V1; Larger R wave V5
- depth of V1 and height of V5 = 35mm

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8
Q

What EKG sign would be indicative of myocardial ischemia? (ischemia, not infarction)

A

Inverted symmetrical T-waves
- caused by a reduced supply of O2 from the coronary arteries

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9
Q

What EKG sign would be indicative of non-salvageable tissue damage (infarct) post acute myocardial infarction?

A

Pathological Q-waves: 1mm wide or ⅓ the height of R-wave in 2 related leads.

S17

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10
Q

Cardiac pacemakers are the treatment for choice for?

A
  • Elderly or SSS
  • anti-bradycardi treatment (either from pathology or medication)
  • (often required temporarily after cardiac surgery)

S19

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11
Q

3 types of pacemakers and what do they consist of?

A
  • Transthoracic, transcutaneous and transvenous
  • Consists of pulse generator and electrode leads

S19

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12
Q

What type of pacemaker is most sensitive to electromagnetic interference?

A

Unipolar
- unipolar leads are negative eletrodes in chamber with the postitive (grounding electrode)

S20

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13
Q

What is the bipolar electrode?

A

both electrodes in chamber being paced

S20- Uses less energy; common

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14
Q

Do Bipolar or Unipolar pacemakers utilize less energy?

A

Bipolar uses less energy (more efficient)

most common

S20

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15
Q

What are the multipolar leads?

A

multiple electrodes within 1 lead but multiple chambers (some leads cross the septum - biatrial or biventricular)

S20

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16
Q

What type of electrocautery is more safe for patients with permanent pacemakers?

A

Bipolar Cautery

Lecture

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17
Q

In what situations would Bi-ventricular pacemakers be utilized?

A

Anywhere were resynchronization therapy is indicated.

  • HF (30-35% EF)
  • BBB
  • Hx of cardiac arrest

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18
Q

Bi-Ventricular pacing has leads where?

A
  • RA
  • RV
  • LV (these are trans-septal)

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19
Q

Purpose of Bi-Ventricular pacing

A

Cardiac resynchronization (CRT)
- improves RV-LV activation time
- increases EF

S25

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20
Q

What is the I generic code for pacemaker function and the possible modes

A

I indicate the chambers paced
- 0=no chamber paced
- A = atrium paced
- V = ventricular paced
- D = dual chamber paced

S21

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21
Q

What is the II generic code for pacemaker function and the possible modes

A

II indicate the chamber sensed
- 0 = none
- A = Atrium
- V = Ventricle
- D = dual sensed

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22
Q

What is the III generic code for pacemaker function and the possible modes

A

III indicate the response to the sensing
- 0 = none
- T = triggered i.e. the pacer is triggered to act based on the sensing
- I = inhibited i.e. the pacer does not act based on the sensing
- D = dual (most common) will both trigger and inhibit

S21

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23
Q

What is the IV generic code for pacemaker function and the possible modes

A

IV indicates rate modulation of the pacer
- 0 = no rate modulation
- R = there is rate modulation

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24
Q

What is the V generic code for pacemaker function and the possible modes

A

V indicates if there is multisite pacing
- 0 = none
- A = atrial
- V = ventricle
- D = Dual

S21

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25
Q

What is the difference between Inhibited and triggered pacemaker mode?

A
  • Inhibited: if intrinsic activity is perceived, chamber is not paced
  • Triggered: pacemaker discharges if intrinsic activity IS sensed; used currently only for testing of devices

S22

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26
Q

Magnets will make the Pacemaker default into what mode? (older models)

A

Asynchronous pacing with no rate modulation
- DOO vs VOO
- this might produce no change in pacing
- Detects battery life response (decreases pulse amplitude or width) Therefore we sometimes have inadequate capture

S27

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27
Q

Perioperative care of AICD and BiV

A
  • Optimize patient condition
  • Turn filter OFF on cardiac monitor
  • Want Bipolar cautery instead of monopolar
  • Back-up pacing ability
  • Interrogation postoperatively

Consider transQ pads if device isn’t working

S28

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28
Q

What is an AICD?

A

Inplantable Cardioverter-Defibrillator
- battery powered to terminate VF or VT
- it measures R-R intervals
- if the R-R are too short, sometimes it can shock like in SVT (10% inappropriate)

S29

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29
Q

Criteria for an AICD shock

A
  • Onset abrubt or gradual
  • VT/VF
  • R-R interval too short (SVT)
  • Variable or consistent R-R interval
  • QRS could be normal or wide

S29

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30
Q

What is a CVP?

A
  • Pressure measured at the junction of vena cava and right atrium (Highly dependent on blood volume and vascular tone)
  • Used for assessment of blood volume and RIGHT heart function (trends instead of 1 number)
  • normal, awake, spont breathing = 1-7mmHg

S32

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31
Q

What causes an (a) waveform on a CVP?

A
  • Atrial contraction
    • occurs after the P wave on EKG
    • increases atrial pressure
    • Provides the atrial kick

S34

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32
Q

What causes the (c) waveform on a CVP?

A
  • Interrupts the decreasing atrial pressure
    • Isovolumetric contraction of the ventricle
    • Tricuspid valve closed and ventricle bulges toward the atria
    • Follows “R” wave

S35

33
Q

What causes the x descent on the CVP?

A
  • Decrease in atrial pressure from a wave through ventricular systole
    • called systolic collapse
    • sometimes called X and X1

S36

34
Q

What causes a (v) waveform on a CVP?

A
  • Venous filling of the atrium
    • during late systole - when tricuspid valve is still closed
    • peaks just after T wave on EKG

S37

35
Q

What causes the Y descent on the CVP?

A
  • Tricspid valve opens
    • called diastolic collapse

S38

36
Q

An h-plateau occers immediately before the ____ wave.

A

a-wave

Schmidt

37
Q

The y descent happens after the ______ wave.

A

v-wave

S38

38
Q

What is the H-wave or H-plateau?

A

Diastolic plateau (not a lot of blood movement until atria contract to produce the a-wave)

From Schmidty

39
Q

The x descent happens after the ________ wave

A

c-wave

S38

40
Q

During atrial fibrillation, loss of the ___ wave and enlargement of the ___ wave occurs to the CVP waveform.

A
  • loss of A-wave
  • enlargement of C-wave

S39

41
Q

What characteristics are seen on a CVP waveform in a patient with significant tricuspid regurgitation?

A
  • Tall Systolic C-V wave
  • Loss of X-descent

Very similar to RV waveform

S39

42
Q

What characteristics are seen on a CVP waveform in a patient with significant tricuspid stenosis?

A
  • Tall A-wave
  • Small Y-descent

S39

43
Q

Describe a Swan-Ganz Catheter in detail.

Flip for picture.

A

S40

44
Q

What does each lumen do in the PA catheter?

A
  • Most distal: monitors PAP
  • 30cm proximal: monitors CVP
  • 3rd lumen: leads to the balloon to wedge the PA
  • 4th lumen: lies just proximal to the balloon, also has the termperature thermistor

S41

45
Q

What is the preferred site for PA catheter placement?

A

Right IJ

S42

46
Q

Where is the PA catheter at based on the waveform below?

A

Right Atrium

S42

47
Q

Where is the PA catheter at based on the waveform below?

A

RV

S42

48
Q

Where is the PA catheter at based on the waveform below?

A

Pulmonary Artery

S42

49
Q

Where is the PA catheter at based on the waveform below?

A

Wedged

S42

50
Q

What is the total length of the PA catheter?

A

110 cm marked at 10cm intervals

S43

51
Q

Normal PAC depth for:
- RA
- RV
- PA
- Wedge

A
  • RA: 20-25cm
  • RV: 30-35cm
  • PA: 40-45cm
  • Wedge: 45-55cm

S43

52
Q

7 Complications of PAC

A
  • Dysthythmias (PACs, PVS, VT runs)
  • RBBB or complete HB
  • Catheter knots
  • Pulmonary infarction
  • Pulmonary artery rupture
  • Endocarditis
  • Valve Injury

VERB DIK

S44

53
Q

What PA catheter complication is associated with very high mortality? What are the presenting s/s?

A

Pulmonary artery rupture

  • Hemoptysis (Bright red and copious)
  • Hypotension

S44

54
Q

How are PA ruptures treated?

A
  • ↑ Oxygenation
  • ETT (might need double lumen)
  • PEEP (to tamponade bleeding - very temporary)
  • Reverse anticoagulation (unless on bypass)
  • Tamponade bleed w/ PA balloon maybe
  • Definitive surgical repair

Thoughts and prayers

S45

Cannot reverse anticoag while on bypass r/t pt will be “deader than dead” -Corn 8/3/24

55
Q

How do you take a PAWP?

A
  • this is an indirect measurement of LA pressure
  • PA diastolic can be used as an alternative (but issues with that too)
  • PAC tip should be in West Zone 3

S46

56
Q

What are the drawbacks of estimating the wedge pressure with the LVEDP?

A
  • Poor estimate of:
    • Compliance
    • Aortic regurgitation (artificially increases)
    • PEEP (artificially increases)
    • VSD (ventricular septal defect)
    • Mitral stenosis/regurg (weird wave)

S47

57
Q

What would a PAC/CVP waveform look like in a patient with mitral regurgitation?

A
  • Tall V-wave
  • C & V wave fused
  • No X-descent

S48

58
Q

What would a CVP waveform look like in a patient with mitral stenosis?

A
  • Slurred, early Y-descent
  • A wave may be absent d/t frequent association with a-fib

S49

59
Q

How will the PA catheter waveform present with an acute LV MI?

A
  • Tall A-waves d/t non-compliant LV
  • Increased LVEDV & LVEDP
  • PAWP increases

S50

60
Q

The Mixed venous equation is a rearrangement of the ____ equation, and the equation is ____

A

Rearrangement of the Fick equation

S51

61
Q

What is the typical range for mixed venous O₂ saturation and what is the O2 carrying capacity of Hgb?

A
  • 70 - 80 % (average 75)
  • 1.34

S54

62
Q

What is the typical range for SVR?

A

800 - 1600 dynes/sec/cm5 (average1200)

S54

63
Q

What is the typical range for PVR?

A

40 - 180 dynes/sec/cm5 (average 80)

S54

64
Q

What is the typical range for stroke volume?

A

60 - 90 mL (average 75)

S54

65
Q

What is bolus thermodilution for the PAC and what is it measuring?

A
  • Cold injected (10ml) and measure a change in temperature downstream
    • Injected RA lumen, measured PA blood by thermister
    • 3 averaged attempts

We measure CO: CO inversely proportionate to degree of change
Subsequent changes of 13% significant

S55

66
Q

What would the following cardiac output thermodilution curve indicate?

A

Low CO (Longer time to return to baseline)

S56

67
Q

What would a high cardiac output thermodilution curve look like?

A

S56

68
Q

Examples of things that would cause thermodilution inaccuracies

A
  • Measures right heart; assumes left heart
    we run into problems with the following:
    • Intra-cardiac shunts
    • Tricuspid/pulmonic regurgitation
    • Mishandling of the injectate (person dependent)
    • Fluctuations in temperature of the pt i.e. Following bypass
    • Rapid fluid infusion (Cold blood? cold meds going in?)

S57

69
Q

How is continuous cardiac output measured?

A
  • Small quantities of heat are released from filament in RV (measured at thermistor)
  • Updated q 30-60 seconds; averaged over 3-6 minutes
  • Compared to thermodilution:
    • Reproducibility/precision better
    • But we have delay in updated information in unstable patients

More accurate during positive pressure

S58

70
Q

If SVV is > ____% then patient is likely to respond well to fluids for hypotension.

A

10%
this relys on an algorithm from end diastole to end systole - and calculates ventricular compliance (+/- 0.5L/min compared to thermodilution)

S59

71
Q

Continuous Cardiac output monitoring and pulse contor inaccuracies

A
  • Atrial fibrillation
  • Site of arterial puncture
  • Quality of arterial trace (Affected by vasopressors)
  • Requires frequent re-calibration (Ideally calibrated initially with a known CO)

S60

72
Q

How many “views” are in a full echocardiogram?

A

28 views

S63

73
Q

What five views can be utilized for a focused TTE?

A
  1. Parasternal Long Axis
  2. Parasternal Short Axis
  3. Apical Four Chamber
  4. Subcostal Four Chamber
  5. Subcostal IVC

S65

74
Q

What is assessed with a parasternal long-axis view?

A
  • Overall Function
  • LA, LV and aortic root

S64

75
Q

What is assessed with a parasternal short-axis view?

A
  • LV function & volume status

S64

76
Q

What is assessed with an apical four chamber view?

A
  • RV vs LV size
  • Tricuspid & Mitral function
  • Descending Aorta

S64

77
Q

What is assessed with a subcostal four chamber view?

A
  • Pericardial Effusion often next to right heart
  • Four chambers

S65

78
Q

What is assessed with a Subcostal IVC view?

A

IVC

  • Diameter
  • Collapsibility (especially in spont respiration)

S65

79
Q

What are the two main contraindications to intra-operative TEE?

A
  • Esophageal Varices
  • Lap Banding

S66

Mar: Sem 4 - Principles II (23 decks)

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