EXAM 2: AP, monitors Flashcards
blood flow through heart
SVC and IVC
RA
Tricuspid valve
RV
pulmonic valve
PA
lungs
pulmonary veins
LA
mitral valve
LV
aortic valve
aorta
what makes up the flexible skeletal structure of the heart
cartilage
-valve annuli
-aortic/pulmonic roots
-central fibrous body
-L and R fibrous trigones
what is the two layer sac that surrounds the heart
pericardium
what is the fibrous sheath of the pericardium made of
mesothelial cells
what is the purpose of the pericardium
protects/lubricates and holds the heart in place
what layer of pericardium contacts the outside of the heart
epicardium/visceral
what layer of pericardium conatins 15-30 ccs of serous fluid between epicardial and parietal space
pericardial space
what layer of the pericardium is adhered to the fibrous outer layer
parietal pericardium
what layer of the pericardium is the outer layer fused to the central tendon of the diaphragm
fibrous pericardium
layers of pericardium
fibrous pericardium
parietal pericardium
pericardial space
epicardium/visceral
heart layers image
what is the inner most layer of the heart
endocardium
what is the middle layer of cardiac muscle
myocardium
what is the outer layer of the heart and the inner layer of the pericardium
epicardium
what is a differentiating factor of pericarditits
positional pain, increased when breathing
what is the thickness of the atria
5mm
what is the thickness of the ventricles
10mm
T/F semilunar valves have cardae tendinae
F, only atrioventricular valves
what does RA receive blood from
SVC, IVC, coronary sinus
what does LA receive blood from
pulmonary veins
atria are formed of _______ thin layers of myocardium
2
what happens if cordae tendinae are damaged/lost
regurg
approximately _______% of CO goes to the heart itself
5
what stage of cardiac cycle is LV perfused
diastole
what stage of cardiac cycle is RA, LA, and RV perfused
systole and diastole
what are the two main coronary arteries
left main
RCA
what does the LMA give rise to
LAD
circumflex
what does the RCA give rise to
PDA
what does the RCA and branches supply
Rt atrium
RV
SA and AV nodes (sometimes)
interatrial septum
small portion of LV
posterioinferior IVS
what does the Left Main perfuse
LA
LV
most of IVS
R and L bundle branches
small part of RV
what cardiac vein parallels the LAD
great cardiac vein
what cardiac vein parallels the PDA
middle cardiac vein
what cardiac vein parallels the marginal branch of the RCA
small cardiac vein
where do all the coronary veins empty
coronary sinus (then RA)
Where is the coronary sinus located?
the posterior aspect of the atrioventricular groove
coronary vessels pic
coronary vessels pic 2
coronary vessel chart
cardiac muscle contracts (longer/shorter) than skeletal muscle
longer
what are the three types of cardiac muscle
atrial muscle fibers/contractile
ventricular muscle fibers/contractile
excitatory/conductive
what structure is cardiac muscle allows AP to travel via ion flow between cells
intercalated disks
contractile muscle fibers of the heart have more ______________ and less ________ than skeletal muscle
mitochondria
sarcoplasmic reticulum
where does calcium influx come from in cardiac muscle
intracellular fluid
what two functions of cardiac muscle allow for better cardiac emptying
twisting motion
long contraction
which direction does the subepicardial (outer) layer of the heart twist
leftward
which direction does the subendocardial layer (inner) contract
rightward
contraction sequence
-AP runs down sarcolemma (cell membrane) to T tubes
-opens L type Ca channels
-Ca influx into sarcoplasm
-Ca ions interact with troponin C
-tropomyosin rotates to uncover myocin binding site on actin
-myosin head binds to actin
-ATP hydrolysis occurs releasing ADP and phosphate
-ratcheting movement between myosin heads and actin
-actin and myocin slide past each other resulting in contraction
troponin has _____ proteins
3
what troponin does calcium bind to
C
how long is the refractory period of the ventricles
0.25 seconds
how long is the refractory period of the atrium
0.15 seconds
why does the atria have a shorter refractory period
thinner muscle
no AV node
what phases make up the absolute refractory period
phase 1,2 and part of phase 3
what phases make up the relative refractory period
phase 3
what is resting membrane potential of cardiac muscle
-90 mv
what is threshold of cardiac muscle
-65 mv
what occurs during phase 4 of the cardiac AP
K leaks out
Na leaks in
T type Ca allow slow influx into cell
L type Ca open at threshold
what occurs during phase 0 of cardiac cycle
depolarizing due to L type Ca
K falls with Ca equilibrium resulting in depolarization
voltage gated K channels open
K equilibrium moves cell to phase 3
what ion repolarizes cell
K
what ion depolarizes cell
Ca
what occurs during phase 3 of cardiac cycle
calcium channels become inactive that opened in phase 0
intracellular Ca drops
phase 3 ends when membrane potential reaches -65 mv
K channels close with repolarization
pacemaker AP pic
what phases are not part of the pacemaker AP
1 and 2
how do beta blockers affect cardiac AP
increased permeability of K and Na
hyperpolarization of cell
what happens with pacemaker and sympathetic activity
-beta 1 receptor activation
-G protein releases adenylyl cyclase
-ATP converted to cAMP which activates protein kinase A
-phosphorylation opens more L type Ca channels
-greater influx of Ca into cell shortens phase 4
How does parasympathetic/vagal response alter pacemaker cell
-acetylcholine binds to muscarinic receptors
-increased K permeability and decreased Ca permeability
-hyperpolarizes membrane
-increases time to reach threshold
-decreases HR
action potential comparisons
which part of the conduction pathway is fastest
bundle branches
Purkinje network
which part of the conduction pathway is the slowest
SA node and AV node
what is the pacemaker rate of SA node
60-100
what is the pacemaker rate of AV node
40-55
what is the ventricular pacemaker rate
25-40
conduction velocity fast to slow
bundle branches and purkinje
bundle of HIS
atrial muyocardium
ventricular myocardium
AC node
SA node
which ventricle contracts first
RV (thinner and first in pathway)
what are cvp distances to right atria
subclavian=10cm
right ij= 15
left ij= 20
femoral vein= 40
right median basilic= 40
left median basilic= 50
what are parts of cvp waveform
a= atrial contraction
c= tricuspid closure
v= filling of r atrium
how does a cerebral oximeter work
skull is translucent to infrared light
travels in arch like (parabolic pattern)
reflects venous return (doesn’t need pulse aka artery)
what is key in cerebral oximeter
look for a change in 20% below baseline
-big drop could mean stroke
how can you increase cerebral oxygenation
-decrease minute ventilation to cause more co2 to cause vasodilation to increase blood flow
what is the distance from the subclavian vein to the R atria
10 cm
what is the distance from the R IJ to the R atria
15 cm
what is the distance from the L IJ to the R atria
20 cm
what is the distance from the right Femoral vein to the R atria
40cm
what is the distance from the R median basilic vein to the R atria
40 cm
what is the distance from the L median basilic vein to the R atria
50 cm
What does CVP measure?
right atrial pressure
what is normal CVP
1-10mmHg
what does CVP estimate
preload
in a CVP waveform what does the a wave denote
atrial contraction
in a CVP waveform what does the c wave denote
tricuspid valve closure (pressure pushed against valve at closure)
in a CVP waveform what does the v wave denote
passive filling of RA (coranaries, IVC, SVC)
where does the a wave of the CVP waveform correlate to the EKG
comes after P wave
where does the c wave of the CVP waveform correlate to the EKG
during QRS
where does the v wave of the CVP waveform correlate to the EKG
t wave/ repolarization
what causes an elevated a wave in CVP waveform
(increased contractile force)
junctional rhythm (atria pushing on closed tricuspid valve)
PVCs
tricuspid stenosis
ventricular pacing
what causes an elevated C wave in CVP waveform
(pushing against tricuspid valve)
pulm htn
mitral insufficiency (regurge)
what are causes of elevated CVP
(elevated preload)
RV failure
tricuspid stenosis or regurge
cardiac tamponade
constrictive pericarditis
volume overload
pulmonary htn
LV failure (chronic)
how does hypovolemia affect CVP waveform
hides abnormalities
what causes a large V wave in CVP waveform
(increased filling pressure)
increased preload
high volume of fluid given
what happens to CVP waveform when you give alot of volume
up and plateaus
what condition causes a lack of a waves in CVP waveform
a fib
with a swan, what is the distance from the Rt IJ to the RA
15-25 cm
with a swan, what is the distance from the Rt IJ to the RV
25-35 cm
with a swan, what is the distance from the Rt IJ to the PA
35-45 cm
what is the approx normal pressure of the RA
5
(no systolic, same as CVP)
what is the approx normal pressure of the RV
25/5
(gain systolic, diastolic mimics RA)
what is the approx normal pressure of the PA
25/10
(systolic same, diastolic increase)
what does a thick line on a swan represent
50 cm
what does a thin line on a swan represent
10 cm
what is the thermistor port on a swan for
CO
CI
what color is the CVP port on a swan
blue
what color is the balloon port on a swan
red
how many ccs go in a swan balloon
1.5 ccs
what color is the PA port on a swan
yellow
what is used to introduce a swan? how big is it? where is it usually placed?
cordis
9 french
Rt IJ
when do you inflate the swan balloon during insertion
RA
what is a common dysrhythmia when inserting a swan
PVCs
if you insert swan from the L side IJ instead of the R how much distance do you add
10 cm
how can you tilt bed to help with swan insertion
R and trendelenburg
what is the A wave on a PAOP or wedge
left atrial contraction
what is the C wave on a PAOP or wedge
mitral valve closure (bulge)
what is the v wave on a PAOP or wedge
filling of L atria
what causes a large a wave on PAOP
mitral stenosis
what causes a large v wave of PAOP
mitral regurg
what causes an elevated PA pressure
LV dysfunction
mitral stenosis/insufficiency
L-R shunt
ASD/VSD
pulm htn
what causes an elevated PAOP
LV dysfunction
cardiac tamponade
constrictive pericarditis. (chronic pericarditis, mimics tamponade)
Ischemia
what three pressures are the same in a patient with cardiac tamponade
PAD
PAOP
CVP
What is the Frank-Starling law of the heart?
the more the heart fills with blood during diastole, the greater the force of contraction during systole (to a point then it fails)
when do you read a PA mean in a spontaneous breathing patient? a ventilated patient
patient peak- diastolic pressure during expiration
vent valley (or just make them apnic)
what does PAOP approximate
LVEDP
PA pressure is and indirect measurement of
ventricular function
what is normal CVP, PADP, PAOP
cvp 1-10
PADP- 5-15
PAOP- 4-12
what causes CVP, PADP, and PAOP to be low
hypovolemia, or misplaced transducer
what causes normal or high CVP, High PADP, and high PAOP
LV failure
what causes high CVP, normal or low PADP, and normal or low PAOP
RV failure
Tricuspid regurge
Tricuspid stenosis
what causes normal or high CVP, High PADP, and normal or low PAOP
PE
what causes high CVP, High PADP, and normal PAOP
Pulm HTN
what causes high CVP, High PADP, and high PAOP
tamponade,
ventricular interdependence,
transducer not at phlebostatic axis
what causes normal CVP, normal High PADP, and high PAOP
LV myocardial ischemia
MR?
what causes low CVP, High PADP, and normal PAOP
ARDS
how do you calulate CO
CO=SVxHR
what is normal CO
5-6 L/min
how do you calculate CI
CI= CO/BSA
what is normal CI
2.8-3.6 L/min
what helps us calculate CO, CI on a swan
thermodilution +/- 5-10%
how does thermodilution work
inject 10ccs ns/d5,
computer reads temp change and when it returns to normal
why is mixed venous drawn from PA
has SVC and IVC blood
what is normal mixed venous
65-77%
what does mixed venous tell us
measurement of O2 delivery, can be an indicator of low CO
What can cause a loss of a waves or only v waves
Afib
Ventricular pacing
What causes giant a waves aka cannon a waves
Junctional rhythms
Complete AV block
PVCs
Ventricular pacing
Tricuspid/ mitral stenosis
Diastolic dysfunction
Myocardial ischemia
Ventricular hypertrophy
What can cause large V waves on cvp
Tricuspid/ mitral regurg
Acute increase in intravascular volume
What can cause elevated CVP
Rv failure
Tricuspid stenosis/regurg
Cardiac tamponade
Restrictive pericarditis
Volume overload
Pulm HTN
LV failure
What can cause elevated PAP
LV failure
Mitral stenosis/regurg
L to R shunt
ASD or VSD
Volume overload
Pulm HTN
Cather whip
What causes elevated PAOP
LV failure
Mitral stenosis/ regurg
Cardiac tamponade
Constrictive pericarditis
Volume overload
Ischemia
What can cause overestimated thermodutjln CO
Low injectate volume
Injectate too warm
Thrombus on thermistor of PAC
Partially wedged PAC
What can cause underestimates of thermodultion CO
Excessive injectate volume
Too cold injectate
RCA branches
SA nodal
right marginal
inferior (posterior) interventricular
AV node
left coronary artery branches
circumflex
LAD
left marginal
location of great cardiac vein
parallels LAD and drains into coronary sinus
middle cardiac vein location
parallels posterior (inferior) interventricular branch and drains into coronary sinus
small cardiac vein location
parallels right marginal artery and drains into coronary sinus
where do anterior cardiac veins drain
several small veins that directly into atrium
smallest cardiac veins drain
drain through the cardiac wall directly into all four heart chambers, but mostly the right atrium
low CVP
Low PADP
low PAOP
hypovolemia
transducer not at phlebostatic axis
normal or high CVP
high PADP
high PAOP
LV failure
high cvp
normal/low PADP
normal/low PAOP
RV failure
tricuspid regurg
tricuspid stenosis
high cvp
high PADP
normal/low PAOP
pulm embolism
high cvp
high PADP
normal PAOP
pulm HTN
high cvp
high PADP
high PAOP
cardiac tamponade
ventricular interdependence
transducer not at phlebostatic axis
normal cvp
normal/high PADP
high PAOP
LV myocardial ischemia
mitral regurg
Low cvp
high PADP
normal PAOP
ARDS
what does the horizontal/x axis represent in a PV loop
volume
what does the verticle/y axis in a PV loop represent
pressure
what is point A in a PV loop
-End Diastole
-Beginning of cardiac cycle
-Full LV ready to contract
-Mitral closure
what is segment AB in a PV loop
-Beginning of systole
-Isovolumic LV contraction on closed aortic valve
-Pressure increase without volume loss
what is point B in a PV loop
-Aortic Valve opening
-Pressure exceeds force to overcome AV
what is segment BC in a PV loop
LV ejection into aorta
-AV is open
-LV is contracting
-LV volume is decreasing
-Gradual pressure increase then decrease
what is point C in a PV loop
-AV closure
-LV pressure drops below AV pressure threshold
what is segment CD in PV loop
-LV isovolumic relaxation
-Empty LV
-AV is closed
what is point D in a PV loop
Mitral Valve opening
what is segment DA in a PV loop
-Filling of the LV
-End of the cardiac cycle
-Pressure and volume gradually increase
describe changes in PV loop with Aortic stenosis
increased Y axis (height)
left shifted and shortened x axis
shorter AB segment
narrow loop
describe changes in PV loop with Mitral Stenosis
L shift
shorter DA segment
BC segment shorter
decreased volume
describe changes in PV loop with aortic regurge
R shift
long DA segment
CD curved
describe changes in PV loop with mitral regurge
shorter AB
higher A point
long BC
long DA
increased SV
pressure volume loops comparison
what is normal size of aortic opening
2-4cm
what is aortic stenosis >1.5
mild
what is aortic stenosis 1-1.5 cm
moderate
what is aortic stenosis <1.0
severe
what is aortic stenosis <0.5
critical
at what pressure gradient do AS patients become symptomatic
> 40 mmHg
at what pressure gradient are AS patients considered severe
> 60 mmHg
at what pressure gradient are AS patients considered critical
80 mmHg
what is most common cause of AS
bicuspid aortic valve
what does the pressure gradient in AS lead to in heart
concentric LV hypertrophy
what happens metabolically with LV hypertrophy
increased myocardial O2 demands
what does in increased pressure gradient lead to circulation wise
reduced coronary perfusion
what do 50% of aortic stenosis patients also have
correlating CAD
what are features of noncompliant LV (LVH)
compromised diastolic filling
dependence on atrial kick
how is LVEDP in concentric hypertrophy
maintained
when is AS valve replacement recommended
symptomatic with severe AS
asymptomatic patient with EF <50%
already having cardiac surgery
what regular heart rhythm do we avoid in AS and why
tachycardia
need time to perfuse coronaries and ventricular filling
increased myocardial O2 demand
in AS do we want Hyper or hypo tension
hyper is better (maintain SVR)
what irregular heart rhythm do we avoid in AS and why
AFIB
need atrial kick
what is goal for preload in AS
full
need volume to stretch noncompliant LV
increased preload decreases gradient across LVOT
LVEDP>LVEDP
what is goal for HR in AS
slow/normal
too fast= ischemia
too slow= not enough CO for coronary perfusion
what is goal for Rhythm in AS
maintain sinus
atrial kick can contribute up to 40%
cardiovert early
what is goal for compliance in AS
improve
thick LV prone to diastolic failure
increased LVEDP reduces coronary perfusion
Cautiously treat with NTG maintaining LVEDV and MAP
what is goal for contractility in AS
maintain
concentric hypertrophy with normal chamber size
normal or increased EF initially
falling EF later
what is goal for SVR in AS
maintain coronary perfusion gradient
hypertension better than hypotension
treat hypotension with phenylephrine
caution with vasodilation
what is goal for PVR in AS
maintain
diastolic failure can lead to dyspnea
what are the two kind of aortic valve replacements
tissue
mechanical
what are properties of tissue AV replacment
most popular
no anticoagulants
10-20 year lifespan
what are properties of mechanical valve AV replacement
can last a lifetime
require anticoagulation
how do we measure aortic regurge
jet size
volume with echo
what is aortic regurge with <30% regurgitant fraction
mild
what is aortic regurge with >50% regurgitant fraction
severe
what kind of structural changes happens with aortic regurge
eccentric hypertrophy
LVEDV 3-4X normal
what are indications for surgery in Aortic regurge
symptomatic
asymptomatic with EF <50%
what is goal for preload in AR
increase
increased volume to maintain forward flow
what is goal for HR in AR
high-normal
decreased diastolic time decreases regurge
avoid brady
what is goal for rhythm in AR
usually sinus
what is goal for compliance in AR
maintain
eccentric hypertrophy can lead to LVEDV 3-4x normal
return large pump volume after bypass to prevent failure
what is goal for contractility in AR
maintain
surgery indicated for EF <55%
may need inotropes after pump
what is goal for SVR in AR
vasodilate to enhance forward flow
what is goal for PVR in AR
maintain
PVR increases rapidly with acute AR= acute failure
what is goal for CPB in AR
decrease LV distension
can develop due to slow HR or nonbeating heart
consider LV vent retrograde of ostial cardioplegia
when does mitral regurge occur
systole
what is MR usually caused by
ischemia
how is EF on echo with MR
often overestimated
a calculated EF of ________% with sever MR represents significant LV dysfunction
<60%
what heart changes does MR lead to
LA and LV eccentric hypertrophy
what rhythm develops in 50% of MVRs
afib
T/F in MR repair is preferred over replacement
true
what is goal of preload in MR
increase or decrease
enhance forward flow
what is goal of HR in MR
high-normal
decreased diastolic time minimizes regurge
avoid brady
what is goal of Rhythm in MR
NSR or if AF control vent rate
what is goal of compliance in MR
maintain
eccentric hypertrophy of LA and LV
what is goal of contractility in MR
maintain
may need inotropes after pump
what is goal of SVR in MR
decreased
cautious vasodilation enhances forward flow
what is goal of PVR in MR
decreased
acute pulmonary edema can develop with MR
May need to treat urgently with MV repair
what is goal of CPB for MR
LV dysfunction can be unmasked after surgery
what is the MAZE procedure for after MR sx
scar the LA to stop AFIB for 12 months
what is the MOA of protamine
protamine is a positively charged protein that forms an ionic bond with heparin, thus rendering it inactive.
what is the DOA of protamine
2 hrs
what do we do PREOP for aortic stenosis patient
2 IVs
A line
Type and Cross
ICU bed
Cardiac consult
EKG/TTE
what do we do INTRAOP for aortic stenosis
have levophed drip
BBs (esmolol)
avoid tachycardia
high narcotic
half nitrous half iso
FULL preload (stretch non-compliant LV)
normal/low HR
Maintain SVR
when is AS valve replacement recommended
symptomatic with severe AS
asymptomatic patient with EF <50%
already having cardiac surgery
what regular heart rhythm do we avoid in AS and why
tachycardia
need time to perfuse coronaries and ventricular filling
increased myocardial O2 demand
in AS do we want Hyper or hypo tension
hyper is better (maintain SVR)
what irregular heart rhythm do we avoid in AS and why
AFIB
need atrial kick
what is goal for preload in AS
full
need volume to stretch noncompliant LV
increased preload decreases gradient across LVOT
LVEDP>LVEDP
what is goal for HR in AS
slow/normal
too fast= ischemia
too slow= not enough CO for coronary perfusion
what is goal for Rhythm in AS
maintain sinus
atrial kick can contribute up to 40%
cardiovert early
what is dromotropy
conduction velocity
what is chronotropy
HR
what is inotropy
force of contraction
tamponade is a ____________ problem
preload
what reflex is forced expiration against a closed glottis producing an increase in intrathoracic pressure and increase CVP
valsava
what reflex is brought on by PPV breath hold
valsava
what is effect of valsava manuever
activate baroreceptor reflex to lower HR and BP
what reflex is brought on by Direct stimulation through decreased blood flow to the vasomotor center
cushings reflex
what are steps to cushing’s reflex
- ICP>MAP hypothalamus increases stimulation of the SNS to the heart * Baroreceptor reflexes kick in and stimulate a PNS response * Bradycardia may also be caused by vagal nerve impingement due to increased
ICP
what is cushings triad (sign of increased ICP/cushings reflex)
HTN
bradycardia
respiratory variability
what causes the bradycardia is cushings triad
baroreceptor response on R branch of the AV node which innervates the SA node
where are chemoreceptors located
carotid and aortic bodies
what nerves do the chemoreceptors utilize
Herings and Vagus
what stimulates the chemoreceptors
decrease in O2 <50
increase in CO2
hydrogen ions/low ph
what reflex may play a role in HTN from OSA
chemoreceptor reflex
the chemoreceptor reflex is not a powerful stimuli until arterial BP falls below ___________
80 mmHg
what reflex is triggered by right atrial stretch receptors
bainbridge reflex
how much can the bainbridge reflex increase HR
75%
what is sensed by the right atrial stretch receptors
increased Rt atrial pressure
when there is an increase in Rt atrial pressure the _________ reflex kicks in, which inhibits the ____________ nervous system
bainbridge
PNS
by what mechanism does the bainbridge reflex inhibit the PNS
nucleus tractus solitarius
what reflex is bradycardia occuring during ocular surgery
oculocardiac reflex
what muscle is specifically invovled in the oculocardiac reflex
medial rectus
what medications do we give to combat the oculo cardiac reflex
glyco
atropine
what is the afferent limb of the oculocardiac reflex
trigeminal nerve
what is the efferent limb of the oculocardiac reflex
vagus nerve
which reflex is caused by Traction or pressure on the structures within the peritoneal and thoracic cavities
celiac reflex
what relfex is caused by insufflation
celiac reflex
what nerve is stimulated by the celiac reflex
vagus nerve
what is a hemodynamic effect of the celiac reflex
decreased preload
what reflex responds to noxious ventricular stimuli sensed by chemoreceptors and mechanoreceptors within the LV wall by
inducing the triad of hypotension, bradycardia, and coronary artery dilation
Bezold-Jarisch Reflex
what is the goal of the Bezold Jarisch Reflex
Reperfusion
what portion of the NS does the Bezold-Jarisch activate
PNS, invoking bradycardia
what are the three physiologic effects of the Bezold Jarisch REflex
hypotension
bradycardia
coronary artery dilation
what reflex is activated by myocardial ischemia or infarction, thrombolysis, revascularization, and syncope
Bezold-Jarisch Reflex
what medication do we give to counteract the Bezold-Jarisch reflex
ephedrine
what part of the cardiac output equation is effected by cardiac tamponade
SV so the patient is HR dependent
what is a Rapid” fluid/blood collection
between the parietal pericardium and visceral
pericardium
cardiac tamponade
when does cardiac tamponade become clinically significant
fluid compresses the heart
how does heart adapt to increased pressure from tamponade
increasing venous pressure
how is preload in tamponade
decreased
what is sign of tamponade on SWAN
increasing and equalizing CVP, PADP, and PAWP
tamponade image
what are acute causes of cardiac tamponade
trauma
post-op CABG
invasive procedures: Cardiac cath procedure
thoracic aortic aneurism repture
what are chronic causes of cardiac tamponade
malignancy
infection
autoimmune
how does cardiac tamponade appeat on EKG
low voltage
ST elevation in all leads or just anterior leads if trauma related
what is a sign of cardiac tamponade after CABG that nurse may notice in ICU
chest tube drainage stops
what is the critical feature of cardiac tamponade
cardiac chamber collapse
which chambers collapse first in tamponade
lowest pressure chambers
RA
LA
RV during systole
how is CO in tamponade
decreased
what part of NS is stimulated by tamponade
SNS
how does doppler flow appear in tamponade
respiratory variability
why do intracardiac pressures rise in tamponade
must rise to equal pericardial pressure
what maintains cardiac output in tamponade
HR
how does SVR respond to tamponade
increases to maintain BP and venous return
what is Becks Triad
for tamponade:
-decreased BP
-increased venous pressure (CVP, JVD distension, PCWP)
-distant/muffled heart sounds
what is a sign of tamponade seen on Arterial wave form
pulsus paradoxus
what is pulsus paradoxus
drop in BP/flattening of ABP wave form on inspiration
what causes pulsus paradoduxus
increased intrathoracic pressure from respiration= decreased RAP
tamponade CXR
how much volume is in pericardial space before tamponade is noticeable on xray
250 ccs
what is the best test for tamponade
TEE or TTE
what volume of tamponade can echo detect
25ml
what feature of tamponade can echo detect that CXR cannot
diastolic dysfunction and collapse
tamponade echo
another tamponade echo
tamponade EKG
what is treatment for tamponade
surgery
pericardiocentesis
pericardial window
how do we manage tamponade
fluid resuscitation
inotropic support
avoid drugs that may decrease HR
what is anesthetic management of tamponade
maintain preload
avoid decrease in SVR and CO
avoid large TV to reduce transthoracic pressures
have surgeon scrubbed and ready to cut prior to induction
have plenty of IV access
T/F decrease preload in tamponade
false
T/F give large TV during tamponade
false
what drug do we have ready to go for tamponade induction
baby epi (10 mcg/ml)
what are characteristics of acute pericarditis
- Common, but goes unrecognized
- Self-limiting, 6 weeks
- Usually viral 30-50%
what do we give for viral pericarditis
NSAIDs
steroids
what is a Dense fusion of parietal and visceral pericardium that limits diastolic filling
constrictive pericarditis
what is treatment for constrictive pericarditis
remove pericardium
T/F removing pericardium fixes constrictive pericarditis
doesnt fix all of it, need inotropes after procedure
what are s/s constrictive pericarditis
- Can mimic cardiac tamponade
- Increased CVP
- Pulses Paradoxus
- Rate dependent C.O.
- Usually heart and lungs appear normal on CXR
- Kussmaul’s sign
- Pericardial knoc
how do heart and lungs appear on CXR with constrictive pericarditis
normal
what is kussmauls sign
deep breath results in an increased CVP
what is the definitive treatment for constrictive pericarditis
pericardiectomy
how do we manage constrictive pericarditis
-Maintain preload
* Don’t decrease HR - maintains the C.O.
* Maintain ionotropic support
what often happens post pericardectomy
drop CO by 15-30%
-overdialtion increases LVEDV, stunning myocardium
how do we treat drop in CO post pericardectomy
inotropes
T/F clinical improvement is immediate post pericardiectomy
false
what reasons do we always use R sided DLT
L upper lobe lobectomy
L pneumonectomy
Aortic stenosis
Mitral stenosis
Aortic regurg
Mitral regurg
