Exam 1 - Cardiac Monitoring (Grayson's) Flashcards by Jennifer Valenciano

left from last yrs class:

What is indicated by the pink highlighted portion of the EKG below?
look at V1 tho…

Right Atrial Hypertrophy

“initial component of P larger in V1” - ppt

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The height of the P wave > ____ mm in any limb lead is continuous with right atrial hypertrophy.
A. 1.5 mm
B. 2 mm
C. 2.25 mm
D. 2.5 mm

D. 2.5 mm

rmbr: normal P wave is 2mm wide by 2mm tall :)

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left from last yrs class:

What is indicated by the blue highlighted portion of the EKG below?
look at V1 tho…

Left Atrial Hypertrophy

“terminal portion of diphasic P in V1 is larger!” -ppt

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

Bi-atrial enlargement

note: a normal P wave in V1 is diphasic, but in bi-atrial enlargement, it is exaggerated… like here^

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What disease processes cause LA hypertrophy? select 2.
A. systemic HTN
B. pulmonary HTN
C. mitral stenosis
D. tricuspid stenosis

A. systemic HTN
C. mitral stenosis

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Right ventricular hypertrophy has more depolarization toward V1, so the QRS in V1 will be:
A. negative
B. positive
C. inverted
D. wide

B. positive

and R waves get smaller…

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Fill in the blanks:

Left ventricular hypertrophy appears with a large ____ wave on V1 and an even larger ____ wave on V5.
A. P; S
B. P; R
C. S; R
D. T; S

C. large S wave on V1; larger R wave on V5

also the depth of V1 + height of V5 = 35 mm

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What EKG sign would be indicative of myocardial ischemia?
A. ST elevation
B. pathological Q waves
C. inverted, symmetrical T waves
D. tall peaked T waves

C. Inverted, symmetrical T-waves

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What EKG change signifies myocardial injury and that the MI is acute?
A. ST elevation
B. pathological Q waves
C. inverted, symmetrical T waves
D. tall peaked T waves

A. ST elevation

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What EKG sign would be indicative of non-salvageable transmural tissue damage post acute MI?
A. ST elevation
B. Q waves 1mm wide or 1/3 the height of the R wave
C. inverted, symmetrical T waves
D. tall peaked T waves

B. Pathological Q-waves: 1mm wide or ⅓ the height of R-wave.

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What is the exposed metal end in contact with endocardium called?
A. lead
B. generator
C. electrode

C. electrode or “epicardial leads”

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What type of pacemaker is more sensitive to electromagnetic interference?
A. unipolar
B. bipolar
C. multipolar

A. Unipolar

only negative electrode in chamber; while pos electrode is grounding

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Which pacemaker has both electrodes in chamber being paced?
A. unipolar
B. bipolar
C. multipolar

B. bipolar - uses less energy (more efficient) than unipolar

common!!

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A pacemaker with multiple electrodes within 1 lead but in multiple chambers is called:
A. unipolar
B. bipolar
C. multipolar

C. multipolar

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Match the pacemaker function with its number:
* rate modulation ———————— I
* multisite pacing ———————— II
* chamber(s) paced ——————— III
* response to sensing —————— IV
* chamber(s) sensed ——————— V

rate modulation = IV
multisite pacing = V
chamber(s) paced = I
response to sensing = III
chamber(s) sensed = II

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Generic code for pacemaker function:

for pacing and sensing:
O =
A =
V =
D =

for response to sensing:
T =
I =
D =

for rate modulation:
O =
R =

for pacing and sensing:
O = none
A = atrium
V = ventricle
D = dual (A+V)

for response to sensing:
T = triggered
I = inhibited
D = dual (T+I)

for rate modulation:
O = none
R = rate modulation

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What can alter the rate modulation function of a pacemaker? select 3.
A. vibration or motion
B. wedge pressures
C. minute ventilation
D. airway pressures
E. right ventricular pressure
F. left ventricular pressure

A. vibration or motion
C. minute ventilation
E. right ventricular pressure

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What cardiac dx might multi-site pacing be used for? select 2.
A. a fib
B. dilated cardiomyopathies
C. LV concentric hypertrophy
D. sick sinus syndrome

A. a fib
B. dilated cardiomyopathies

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Which EKG strip shows a DDD pacemaker?

C. Atrial spike and then atrial cxn … then, vent spike and vent depolarization = av sequential pacemaker aka DDD (corn’s words)

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What is a part of our perioperative care of pacemakers? select 2.
A. only monopolar electrocautery around pacemakers
B. ensure grounding pad is distant from pacemakers
C. turn filter OFF on cardiac monitor
D. interrogation only post op

B. ensure grounding pad is distant from pacemakers
C. turn filter OFF on cardiac monitor
and:
- NO MONOpolar electrocautery around pacemakers
- interrogation pre/post-op is not usually req’d

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What are the 3 chambers paced with Bi-V pacemaker?

right atrium and both ventricles (trans-septal)

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In what situations would Bi-ventricular pacemakers be utilized? select 3.
A. atrial enlargement
B. STEMI
C. hx of cardiac arrest
D. EF 30-35%
E. BBB
F. a-fib

Anywhere were resynchronization therapy is indicated.

C. hx of cardiac arrest
D. EF 30-35% = mod/severe HF
E. BBB

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How do AICDs work?

A. sense intrinsic activity
B. measure R-R intervals
C. wait to sense for SVT
D. measure P-P intervals

B. measure R-R intervals (consistent or variable)

also measure QRS width, and onset abrupt/gradual

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An important consideration about perioperative care of AICD/BiV pacemaker is:

A. use bipolar cautery instead of monopolar
B. keep filter ON on cardiac monitor
C. they do not have back-up pacing ability
D. interrogate preoperatively

A. use bipolar cautery instead of monopolar

and:
* keep filter OFF on cardiac monitor
* back-up pacing ability
* interrogate postoperatively

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# *left from last yrs class* Label the a, c, & v waveforms on the Wiggers diagram below.

Where is CVP measured? A. right IJ B. jxn of right atrium and right ventricle C. zone 3 D. jxn of vena cava and right atrium

D. jxn of vena cava and right atrium ## Footnote *highly dependent on blood volume and vascular tone*

What is normal CVP for someone that is awake & spontaneously breathing?

1-7 mmHg

Select 3 that describe the A wave: A. provides "atrial kick" B. follows R wave C. systolic collapse D. ventricular cxn E. occurs after the "P" wave on ekg F. atrial contraction

A. provides "atrial kick" E. occurs after the "P" wave on ekg F. atrial contraction

The C-wave interrupts the decreasing atrial pressure because it is: A. atrial contraction B. systolic collapse C. isovolumetric contraction of the ventricle D. venous filling of the atrium

C. isovolumetric contraction of the ventricle - *so tricuspid valve is closed and ventricle bulges toward the atria* ## Footnote *also, it follows the "R" wave on EKG!*

What is the X-descent/x-wave on CVP waveform? A. increase in atrial pressure from a wave thru ventricular diastole B. decrease in atrial pressure from a wave thru ventricular systole C. decrease in atrial pressure from a wave thru ventricular diastole D. increase in atrial pressure from a wave thru ventricular systole

B. decrease in atrial pressure from a wave thru ventricular systole = also called SYSTOLIC COLLAPSE ## Footnote *r vent cxn, while atria relaxing.*

The V-wave follows the systolic collapse (x-descent) and signifies: A. atrial contraction B. ventricle bulging into the atria C. venous filling of the atrium D. opening of the tricuspid valve

C. Rapid venous filling of the atria - occurs during late systole and tricuspid valve remains *closed* ## Footnote *and peaks just after the "T" on EKG!*

The Y-descent is: select 2. A. systolic collapse B. diastolic collapse C. when tricuspid valve opens D. when tricuspid valve closes E. right ventricle contracting while atrium relaxing

B. diastolic collapse C. when tricuspid valve opens *and initial blood flow into the ventricles from atrium in early diastole*

What will the CVP waveform look like for a patient with atrial fibrillation? select 2. A. no x-descent B. tall a wave C. absence of a wave D. larger c wave

C. absence of A-wave D. larger C-wave *(b/c more volume)*

What characteristics are seen on a CVP waveform in a patient with significant tricuspid regurgitation? select 2. A. no x-descent B. tall a wave C. absence of a wave D. larger c wave E. tall systolic C-V wave

A. no x-descent E. tall systolic C-V wave ## Footnote *valve is incompetent, so atrium pressure can't decrease if constantly being filled from both directions...*

What characteristics are seen on a CVP waveform in a patient with tricuspid stenosis? select 2. A. no x-descent B. tall a wave C. absence of a wave D. larger c wave E. attenuated y-descent

B. tall a wave E. Attenuated Y-descent - *b/c this is when tricuspid valve should normally open but here, its stiff/slower*

# *left from last yrs class* Describe a Swan-Ganz Catheter in detail. *Flip for picture*.

What is the preferred site for PA catheter placement? A. left IJ B. left EJ C. right IJ D. right EJ

C. Right IJ

Where is the PA catheter at based on the waveform below? and whats the depth in cm at this point?

Right Atrium = 20 - 25 cm

Where is the PA catheter at based on the waveform below? and whats the depth in cm at this point?

Right ventricle = 30 - 35 cm

Where is the PA catheter at based on the waveform below? and whats the depth in cm at this point?

Pulmonary Artery = 40 - 45 cm

Where is the PA catheter at based on the waveform below? and whats the depth in cm at this point?

*Wedged* in the PA = 45 - 55 cm

What is the total length of the PA catheter?

110 cm ## Footnote *marked at 10 cm intervals*

A pulmonary artery catheter has just been placed and now you're patient is getting sicker. What s/sx are highly suggestive of a PA rupture? select 2. A. chest pain B. PVCs C. hemoptysis D. new onset bilateral crackles E. hypotension

C. Hemoptysis E. Hypotension

Treatment of a PA rupture includes: select 3. A. endobronchial intubation w/ double lumen tube B. give 1 unit PRBCs and albumin 5% C. add/increase PEEP D. withdraw catheter and place a new one E. reverse anticoagulation unless pt is on bypass F. crack sternum and hold manual pressure

A. endobronchial intubation w/ double lumen tube *(or single lumen, but just ensure adequate oxygenation)* C. add/increase PEEP *(to tamponade bleeding)* E. reverse anticoagulation **unless pt is on bypass** other options: - bronchoscopy to control bleeding - Tamponade bleed w/ catheter by floating balloon into rupture - Definitive surgical repair *(oversew PA, resection)* ## Footnote *Thoughts and prayers*

In order to get an accurate pulm artery wedge pressure (PAWP), where should the PA catheter tip be? A. in zone 1 B. where the PA > Pa > Pv C. where the Pa > Pv > PA D. in zone 2

C. where the Pa > Pv > PA *aka zone 3!*

What would a PAC waveform look like in a patient with mitral regurgitation? select 2. A. tall a wave B. no X descent C. tall V wave D. slurred, early Y descent

B. No X-descent C. **Tall V-wave** *and the C & V wave fused* ## Footnote *b/c V wave is when venous filling of atria occurs and with mitral regurg, there's alot of volume there causing high atrial pressures = tall V*

What would a PAC waveform look like in a patient with mitral stenosis? A. slurred, early Y descent B. no X descent C. no Y descent D. tall A wave E. tall V wave

A. Slurred, early Y-descent - *valve too stiff so the pressure is slow to go down when ventricle should be filling..* ## Footnote *ALSO A wave may be absent d/t freq association w/ a fib*

How will the PAC waveform present with an acute LV MI? A. tall V wave B. tall C wave C. tall A wave D. no x descent E. slurred, early Y descent

C. Tall A-waves *due to non-compliant LV* ## Footnote *will see increased LVEDV & LVEDP = PAWP increases*

What is the typical range for SVR?

800 - 1600 dynes/sec/cm5 ## Footnote avg: 1200 dynes/sec/cm5

What is the typical range for CO?

4 - 6.5 L/min ## Footnote avg: 5.0 L/min

What is the typical range for PVR? average?

40 - 180 dynes/sec/cm5 avg: 80 dynes/sec/cm5

What is the typical range for stroke volume?

60 - 90 mL ## Footnote avg: 75 mL

What is the typical range for mixed venous O₂ saturation?

70 - 80 % ## Footnote avg: 75%

When measuring bolus thermodilution, the area under the thermodilution curve is ____ to the CO. A. proportional B. inversely proportional C. unrelated

B. inversely proportional

What would the following cardiac output thermodilution curve indicate?

Low CO (Longer time to return to baseline = *high area under curve*)

What would a high cardiac output thermodilution curve look like?

small/little area under curve = HIGH CO *(gets back to normal temp quicker)*

What could cause some inaccuracies on thermodilution curves? select 2. A. patient could be fluid overloaded, altering the curve B. tricuspid/pulmonic regurgitation C. rapid fluid infusion D. mixed venous sats may be low already

B. tricuspid/pulmonic regurgitation C. rapid fluid infusion

What has better reproducibility/precision compared to thermodilution? A. pulse contour devices B. continuous cardiac output monitor C. mixed venous O2 sats D. TTE

B. continous cardiac output - *but delays info on unstable pts ..* ## Footnote *cause updated every 30-60 seconds, avg'd over 3-6 mins*

Continuous cardiac output monitors are more accurate during: A. spontaneous ventilation B. inverse ratio ventilation C. PPV D. assist control ventilation

C. PPV

Pulse contour devices measure the area under the curve of arterial pressure tracings. These devices estimate CO, ____, and ____. (select 2) A. wedge pressure B. PPV C. pulse pressure D. stroke volume variance

C. pulse pressure D. stroke volume variance ## Footnote if SVV > 10%, give fluids

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

10%

Pulse contour devices rely on algorithm and measure from end diastole to end systole. What is this calculating? A. atrial compliance B. ventricular compliance C. mixed venous o2 sats D. ventilator compliance

B. ventricular compliance

What five views can be utilized for a focused TTE?

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

Where is your window for the parasternal view? A. at point of maximal impulse B. just below xiphoid C. 3-5 intercostal space D. 4-6 intercostal space

C. 3-5 intercostal space

Where is your window for the *apical* view? A. at point of maximal impulse B. just below xiphoid C. 3-5 intercostal space D. 4-6 intercostal space

A. at the point of max impulse (PMI)

Where is your window for the *subcostal* view? A. at point of maximal impulse B. just below xiphoid C. 3-5 intercostal space D. 4-6 intercostal space

B. just below xiphoid

What is assessed with the parasternal long-axis view?

- Overall view - Left atrium, left vent and aortic root

What is assessed with a parasternal short-axis view?

- LV function & LV volume status

What is assessed with an apical four chamber view?

- RV vs LV size - Tricuspid valve & Mitral valve function - Descending Aorta

What is assessed with a subcostal four chamber view? What can be seen often next to R heart in this view?

- Four chambers - pericardial effusion

What is assessed with a Subcostal IVC view?

- IVC **Diameter** & **Collapsibility** (especially in determining volume status in spontaneous respiration!)

What are the **two** main contraindications to intra-operative TEE? A. pregnancy B. esophageal varices C. congestive HF D. lap banding

B. Esophageal Varices D. Lap Banding

What is important to note about TEE vs TTE regarding the image? select 2. A. posterior structures are closer to transducer in a TEE B. posterior structures are closer to transducer in a TTE C. anterior structures are closer to transducer in a TEE D. anterior structures are closer to transducer in a TTE

A. posterior structures are closer to transducer in a TEE D. anterior structures are closer to transducer in a TTE