Final Flashcards
Identify the % Sensitivity for Detecting MI using Lead II, V5
80%
List the six causes other than MI which may affect ST segment
1) L/R ventricular strain (LVH, RVH)
2) Conduction defects
3) Meds- digitalis or quinidine
4) Pericarditis, pericardial effusion
5) Intracranial hemorrhage
6) Decreased temp
Single best monitor of heart functions and perfusion to vital organs.
Non-invasive BP monitor
SBP-> “return to flow”
DBP-> “muffled lost sounds”
Six clinical indications for INVASIVE BP monitoring.
1) Continuous real-time monitoring
2) Anticipated CV instability
3) Intentional pharmacologic or mechanical CV manipulation
4) Failure of indirect BP measurement (ie morbid obesity)
5) Supplementary diagnostic clues
6) ABG sampling
Compare radial, brachial, and femoral artery cannulation for measuring BP
1) radial: preferred due to ease of access, DECREASED complication rate
2) brachial: median nerve damage potential, clotting
3) femoral: easy access/more accurate in low flow states, more central and need longer catheter
Four benefits of use of US-guided arterial cannulation
1) Greater success rate on first attempt
2) DECREASED overall attempts
3) INCREASED patient comfort
4) Useful in low or non-pulsatile flow and non-palpable pulse
Three Disadvantages of use of US-guided arterial cannulation
1) Infection if poor sterile technique
2) Additional training required
3) Equipment costs
Four clinical parameters which may be assessed with analysis of arterial waveform.
1) Ps-> SBP; Pd -> DBP
2) As -> stroke volume
3) Dicrotic notch -> AV closure
4) Dp/dt-> contractility
Six potential complications with arterial cannulation.
1) Infection
2) Hemorrhage
3) Thrombosis and distal ischemia
4) Skin necrosis
5) Emboli (central, peripheral)
6) Inaccurate pressure measurements
Pros and Cons of EXTERNAL JUGULAR VEIN
Pros:
1) Compressible, ease of insertion
2) Superficial location
3) Less change of pneumothorax or carotid puncture
Cons:
1) Success less likely
2) Difficult sterile dressing
3) Increased incidence of thrombosis
4) Decreased success, kinks at SC
Pros and Cons of INTERNAL JUGULAR VEIN.
Pros:
1) Compressible, ease of insertion, good landmarks
2) Straight shot for PAC
3) Less chance of pneumothorax
Cons:
1) Carotid puncture
2) Hard of obese/fat neck
3) Increased in infection
Pros and Cons of Subclavian Artery.
Pros:
1) Reliable landmarks and positioning
2) No restrictions when in C-collar or trache
3) Decreased infection rate
Cons:
1) More difficult than IJ
2) Noncompressible (avoid in coagulopathy)
3) Risk of pneumothorax or effusion
Pros and Cons of Femoral Vein.
Pros:
1) Ease of placement
2) Compressible
3) No risk of pneumothorax
4) T-burg not necessary
Cons:
1) Increased risk of thrombosis and infection
2) Hard to float PAC
3) Retroperitoneal bleed
4) Pt must be immobile
Five Limitations of using CVP as an index of ventricular filling
1) Unless very high or very low, only useful as a TREND
2) Decreased right ventricular compliance/function may misrepresent left ventricular filling pressure
3) Dependent on venous patency (tumor or vein patency)
4) Tricuspid valve disease misrepresents LVEDP
5) Positive pressure and rapid volume infusion falsely elevates
Atrial and ventricular events associated with CVP trace.
1) “a” wave: atrial contraction
2) “c” wave: isovolumic ventricular contraction (prior to AV opening)
3) “v” wave: ventricular contraction, systolic filling of atrium
4) “x” and “y” wave: ventricular filling and diastolic collapse
Twelve CVC line complications.
1) Accidental arterial puncture (hematoma, false aneurysm)
2) Catheter-induced dysrhythmias
3) Misinterpretation of data
4) Infection
5) Pneumo/Hemo thorax
6) Airway compromise
7) Tracheal puncture
8) Air embolism
9) Catheter wire shearing/new foreign body
10) Thrombophlebitis
11) Cardiac tamponade
12) Nerve injury
Six indications of PAC insertion
1) LV dysfunction
2) Two-vessel Disease/angina within 48 hours
3) Symptomatic valvular disease
4) Severe HTN + angina history
5) Large operation with anticipation of intravascular volume changes
6) Vascular surgery with clamp of major artery
Contraindications for PAC insertion
Absolute:
1) Triscuspid or pulmonary stenosis
2) Right atrial/ventricular mass
3) Tetrallogy of Fallot
Relative:
1) Severe arrhythmias
2) Coagulopathy
3) Newly inserted pacemaker wires
Six indications of PACING PAC.
1) Sinus node dysfunction or symptomatic bradycardia
2) Second degree (Mobitz Type II) AV block
3) Complete/Third Degree AV block
4) DIG toxicity
5) Need for AV sequential pacing
6) Left BBB
“Floating” the PAC (RIJ)-Typical distances to the right atrium, right ventricle, and pulmonary artery.
1) 20 cm: right atrium, CVP trace
2) 30 cm: right ventricle
3) 40 cm: pulmonary artery
4) 50-55 cm: PCWP-should wedge
**DO NOT FLOAT PAST 65 cm
Describe waveform changes differentiating between RA, RV, PA, and PCWP
See pic pg. 46 of power point
List seven factors that may increase filling pressure (PAP and PCWP).
1) Decreased/Increased ventricular compliance
2) Myocardial Ischemia
3) Valve dysfunction
4) Increased filling/volume overload
5) Decreased volume and blood loss
6) Increased Afterload
7) Lung compliance
PCWP > LVEDP (7 instances)
1) Positive Pressure ventilation
2) PEEP
3) Increased thoracic pressure
4) COPD
5) Increased PVR
6) Left atrial myxoma
7) Mitral valve disease (stenosis, regurgitation)
3 instances when PCWP < LVEDP
1) Non-compliance left ventricle
2) Aortic regurgitation (premature closure of mitral valve)
3) LVEDP > or equal to 25 mm Hg
Factors Affecting the Accuracy of Bolus Cardiac Outputs
1) Inaccurate injectate temp or volume (3-10% increase)
2) Rapid volume infusion during injection (20-80% decrease)
3) Respiratory cycle variance (30-60%)
4) Inaccurate computation constant (1-100%)
5) Thermal instability post CPB (10-20%)
Clinical Uses of PAC DATA.
1) Measure CO and optimize perfusion
2) Detect, treat and trend myocardial ischemia
3) Measure and optimize ventricular preload and volume in surgery with large volume shifts
4) Measure and optimize ventricular preload and volume in surgery during aortic-cross clamp
5) Detect, treat, and trend valvular dysfunction
Hemodynamic components used in manipulation of coronary perfusion pressure. (Supply and Demand of Myocardial Oxygen Balance)
Supply:
1) Heart rate
2) PCWP
3) DBP
4) O2 sat; HCT
5) Cor Art Dz
Demand:
1) Heart rate
2) PCWP
3) SBP
4) CO
Relationship of Frank/Starling Curve to using filling pressure/volumes to manipulate cardiac output.
Normal curve: Higher, shorter duration
Lower curve: shorter, longer duration indicating HF, low perfusion state, and pulmonary or venous congestion
