Lecture 11: Diagnostic and Surgical Intervention Flashcards
Diagnostic tools: Cardiac:
* Chest X-ray (primary imaging when pathology expected)
* Electrocardiogram (EKG = one of first diagnostic tools)
* Exercise & Stress Testing
* Echocardiograph
* Cardiac Imaging
* Invasive Monitoring
Pulmonary:
* Chest X-Ray
* CT
* Pulmonary arteriography
* Ventilation/Perfusion scans (V/Q scans)
* Blood gas analysis - arterial blood drawn and paO2 and paCO2 are anaylzed
Most common radiograph used for cardiac and pulmonary disease. Easy to determine heart size, lungs, blood vesseks and pulmonary vasculature
Chest X-ray
Electrical activity of the heart in voltage versus times
* 3 types
ECG (EKG)
1) Rhythm strips
2) Twelve lead
3) Holter monitoring - those that have to have extensive ecgs have - these can be 24 hours+ just to catch any arrythmias
Measure physiological stresses of increased workload
Exercise and Stress testing
basically just how the heart can handle stress
* Can be done through exercise stress test or nuclear stress test (chemicals injected to increase HR and see how well the heart reacts under stress)
Chest X rays
Identifying structures
we can see that the heart is actaully resting pretty low
The guy is wearing an holter monitor
* You cant get it wet, so you can’t shower w/ it on
* Has several leads placed on you (5)
* Should go through normal activities - looking to see if you have arrythmias over time
* If they have any symptoms there a button they push - it basically just markers that area - but its recording continuously
One on the right is a 12 lead one (I think)
* each one of them takes a picture of the heart from a different angle (except for grounding electrodes are - they don’t do this)
* Snow over Grass, Smoker over Fire
Echocardiagram:
Often called an echo
Just like an ultrasound
Uses sound waves to have an image of the heart
can use infrared setting and see bloodflow through heart
* can see the heart pumping in live videos (BF through heart)
A good way to get eh ejection fraction before surgery (get cleared for surgery)
* transthoracic echo most common type
* Patient lies in different positions and has this done
theres also one that goes internally (camera through mouth / esophagus so you can look at the valves a little bit better)
-ectomy
to remove
-oplasty
to reconstruct
-ostomy
to make an opening
-otomy
to cut into
-scopy
to examine by inserting a scope
EX:
* mastectomy
* tracheostomy
* Angeioplasty
* Lobeectomy
* Sternotomy
* Bronchoscopy
Cardiac surgeries
* Thoractomy
* Sternotomy
* Chest Tube placement
* Percutaneous revascularization procedures
* Automatic implantable cardioverter defibrillator
* Defibrillator
* Coronary artery bypass
* Minimally incasive, robotic surgery
* Extracorporeal life support
* Ventricular Assist Devices
What is this
Thoracatomy
cutting into the thoracic acvity
* may be used for a lung transplant (just some way to get into the thoracic cavity)
KNOW:
* We are there to provide splinting for pain, splinted cough techniques, incentive spirometer, functional mobility to increase chest expansion and airway clearance (good way to do this is to get them out of bed)
Thoracotomy
* if they did a lateral cut you have to pay attention to what muscles are cut into
* Note there is also nerve involvement in this area that can be affected
* Doesnt always have to be cut, maybe they were able to move the musculature to the side w/o incision.
* KNOW what muscles might be affected depending on the cut (think lat, serratus anterior and teres minor for a lateral incision)
* also know the nerves of these because she may ask which nerves are impacted.
Medial sternotomy: incision is typiacally longitundinal along the sternum (cutting it entirely in half)
* Typically done to access the heart for a CABAG
Sternal precaustions
* timeframe
* Wt to be lifted
* where can’t you reach
* What can’t you do w/ arms (3)
4-12 weeks depending on healing/surgeon
No lifting more than 5-10 pounds (gallon of milk = 8 pounds)
No reaching behind back
No pushing or pulling through arms
Sometimes no reaching overhead
Another name for internal defibrillator?
Cardiac pacemaker
Wire delivers a shock whenever it thinks something is wrong with the electricity in the heart
* actually implanted in the heart
May be on the left or right side
* important to know because theres percautions to know
Robotic surgery
* Common for what?
Commonly used for valve repair or replacement
* typically aortic valve replacements
can also do an endoscopic cornary bypass
* everything inside the pt (less chance of infection)
Ventricular Assist devices
Assists the ventricle when there is heart failure (typically assists the LV to pump)
* So it helps the heart to pump because its not pumping effectively
* They actaully have to wear all the shit in the picture below
* Can be outside walking and have this (doesnt have to be in hospital to have this)
* Think waiting for a heart transplant or just needing it to assist the heart
Extracorporeal Life support (second picture)
* Mainly for oxygenation
* Pumps oxygen in
* Can be cardiac or pulmonary comprimise
Angioplasty
* typically for cornary artery
* its a percutaneous coronary intervention (PCI) - immade intervention done for myocardial infrac/ischemia
A dye is inserted. Goes through a stent thats put in radial or femoral artery
* shows coronary blood flow in real time
* Done in lab, so if there is a blockage, they can go ahead and move into an intervention (clearing that artery)
When theres a blcokage they can insert a baloonto inflate and expand in the coronary artery so the plaque is pushed out of the way, then the balloon deflate. Can put stent in after that if needed
artery w/ dye in it (arrow shows narrowing due to blockage)
Risk factors that predispose canidates to carciac complications:
Location of surgery
* Aortic
* PVD
* Intrathoracic surgery (opening up thoracic cavity)
* Carotid endarterectomy
* Head and neck surgery
Patient releated factors
* Ischemic heart disease
* MI in last 6 months
* CHF
* Cm, renal insufficiency, cerebrovascular disease
Other:
* emergency surgery - normally becauses severe / life threatening
* General Anesthesia (instead of mild sedation)
* > 3 hr surgery (typically because risky / complex surgery)
Chest tube placement
Used for collapsed pneumothorax, hemothorax, or to evacute any fluid or air from pleural space
Inserted into the intercostal space, tubing secured with minimal suturing
Portable suctions available, must be kept upright and below the level is providing trainage (because physics)
very painful, musculature is cut through
* often done after trauma from that pneumothorax
purple fluid shouldnt be there - use this to drain it
Lung Resections:
* often done w/ malignancy (or significant scarring)
Lobectomy = lung lobe taken out
Pneumoectomy = entire lung taken out
wedge resection = small part of lung taken out
Segmenectomy = segment of lung taken out
* typically follows that bronchiole tree
Organ transplantation
* extensive process –> lots of testing to assess match etc…
* urgency / transplant survival rated highest
* patients will typically be on prehab
Preopeartive rehab program
* [atient and family education
* Cardiovascular endurance training
* MSK strength and flexibility training
* Breathing retraining
Canaidates
* Extensive testing to assess urgency, transplant survival, match, age, and travel/proximity efficiency
Organ transplantation
Lung Composite allocation score - can have living donors for this
* Scoring system used to asses who gets a lung transplant
* Candidate medical urgency (max = 25 points)
* Likelihood of recipient survival over five years post transplant (max 25 pounts)
* Potential biological challenges in matching, such as the candidates blood type, height or immune sensitivity (max 15)
* Whether the candidat was younger than age 18 whe listed a transplant (20 pounts)
* whether the candidate was a prior living organ donor (five points) - donated kidney before
* Closer to higher score = need it more
Heart transplant:
* Most medically urgent first
* A match with the donors blood type
* Listed at a transplant hospital relatively close to the donor hospital - because donor is dead so they will need to do this quickly
Incision types for lung transplants
2 under peck is less invasive than the massive 1 thats attached
* think about muscles that might be comprimised
KNOW: the organs themselves have nerve innervation that might be affected.
Critical condition of systemic hypoperfusion - you’re not getting enough blood
- hypotension (main symptoms)
- tachycardia (main symptoms)
- tachypnea (main symptoms)
Shock
* often happens w/ sepsis
Progressive infection condition (on systemic level)
Sepsis
common in hospitals and after surgery
often occurs w/ shock
things that happen w/ sepsis
Cardiogenic shock
compensated hypotension
characterized by reduced CO output that stimulates compensatory mechanisms that alter myocardial function and peripheral resistance
Cardiogenic shock stage 1
Compensatory mechanisms for dealing w/ the low delivery of nutrients to the body are overwhelmed, and tissue perfusion is decreased
cardiogenic shock stage 2
Charcterized by severe ischemia with dmage to tissues by toxins and antigen-antibody reatcions
Cardiogenic shock stage 3
