heart failure + shock

Question 1

↑ myocardial O2 demand can be due to:

Answer 1

↑afterload (proportional to arterial pressure)
↑contractility
↑HR
↑ventricular diameter (↑wall tension - reason for LVH with ↑afterload to ↓wall tension)

Question 2

conditions with ↑ pulse pressure

Answer 2

hyperthryoidism
aortic regurgitation
arteriosclerosis
obstructive sleep apnea (↑symp tone)
exercise (transient)

Question 3

conditions with ↓ pulse pressure

Answer 3

aortic stenosis
cardiogenic shock
cardiac tamponade
advanced heart failure

Question 4

treatment of chronic heart failure

Answer 4

improve survival:
ACEi/ARB
aldosterone antagonist (spironolactone, eplirinone)
B blocker (metoprolol, carvedilol, bisoprolol)
symptom relief:
diuretics (loop mostly or thiazide)
digoxin
vasodilators (nitroglycerin - venous + hydralazine - arterial)

Question 5

treatment of acute heart failure (pulmonary edema - foam in mouth, peripheral edema)

Answer 5

NO LIP
Nitroglycerin (treat pulm edema: dilate veins → blood pools outside lungs + ↓preload)
O2
Loop diuretics (treat pulm edema → urinate fluid in lungs)
Inotropic agent - if all others faill (doputamine - adrenergic agonist, phosphodiesterase inhibitor - milrinone)
Positioning - sit up, pooling in legs no tlungs

Question 6

type of edema due to excess amount of fluid (like water balloon) in absence of additional colloid, gravity-dependent (in legs)

Answer 6

pitting edema:

press tibia and leaves pit for several minutes

Question 7

type of edema due to excess colloid in interstitial fluid (like jello) which attracts excess fluid
can occur in lymphatic obstruction

Answer 7

non-pitting edema

Question 8

type of edema to due ↑capillary pressure or ↓plasma proteins, protein-poor edema fluid

Answer 8

transudate edema

Question 9

type of edema due to ↑capillary permeability, protein-rich edema (leak fluid + protein)

Answer 9

Exudate edema (has EXtra stuff)

Question 10

femoral vein central line

Answer 10

pro: easiest site, least risk
con:

Question 11

subclavian vein central line

Answer 11

pro: easy placement (good landmarks), last 3-4 wks, less discomfort
con: highest risk of pneumothorax (need CXR to confirm none and ensure not in RV), not good option if COPD (barrel chest) or lung tumors

Question 12

internal jugular vein central line

Answer 12

pro: easy placement (good landmarks), last 3-4 wks
con: more discomfort, risk of puncturing carotid or pneumothorax

Question 13

preferred location of swan ganz catheter

Answer 13

measure LA pressure (diagnose left sided heart failure)
SVC→RA→RV→stays in pulmonary artery - balloon filled
right IJ>left SC (easier angle from L brachiocephalic)>right SC (hard right angle from R brachiocephalic)>left IJ

Question 14

vasopressor for anaphylactic shock

Answer 14

epinephrine

Question 15

cardiac drug used in cardiogenic shock

Answer 15

dobutamine - stimulate ß1 R in heart

Question 16

vasopressor for septic shock

Answer 16

NE - stimulate α1 only - vasoconstrict