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PDF focus Flashcards

1
Q

What is the pathway through the heart?

A

SA node

Internodal tracts

AV node

bundle of His

Bundle Branches

Purkinje fibers

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2
Q

What are the three internodal tracts?

A

1.Anterior (Left) Bachmann bundle

  1. Middle - Wenckebach
  2. Posterior - Thorel
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3
Q

What are the three conduction velocities?

A
  1. SA + AV - 0.02 (Slow conduction)
  2. HIS, Branches, Purkinjie - 1.0 (Fast)
  3. Myocardium - 0.1 (Intermediate)
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4
Q

What is conduction velocity a function of?

A
  1. RMP
  2. Amplitude of action potential
  3. Rate of change in phase 0
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5
Q

What five things affect conduction velocity?

A

ANS tone
Hyperkalemia
Ischemia
Acidosis
Antiarrhythmic drugs

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6
Q

What are the accessory pathways?

A

Bypasses normal conduction pathway

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7
Q

What is the James fiber pathway?

A

Atrium to the AV node

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8
Q

What is the atrio-Hisian fiber?

A

Atrium to HIS bundle

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9
Q

What is Kents bundle?

A

Atrium to ventricle

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10
Q

What is Mahaims bundle?

A

AV node to ventricle

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11
Q

What happens during phase 0 of ventricular action potential? Ion Movement?

A

Depolarization (QRS)

Na+ rushes into cell - making it more positive

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12
Q

What happens during phase 1 of ventricular action potential? Ion Movement?

A

Initial repolarization (QRS)

Cl- moves in and K+ moves out

(downward deflection since it is becoming more negative inside the cell)

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13
Q

What happens during phase 2 of ventricular action potential? Ion Movement?

A

Plateau phase (QT interval)

Ca + in and K+ out

Balance each other out so it is a straight line

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14
Q

What happens during phase 03 of ventricular action potential? Ion Movement?

A

Final repolarization (T wave)

K+ out

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15
Q

What happens during phase 4 of ventricular action potential? Ion Movement?

A

Resting phase (T wave to QRS)

Na+ out

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16
Q

When is the absolute refractory period?

A

Between phase 0/1 and ends in the middle of phase 3

NOTHING can stimulate the cell

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17
Q

When is the relative refractory period?

A

Middle of phase 3

VERY STRONG stimulus is required

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18
Q

What can be seen with PR depression?

A

Pericarditis

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19
Q

What condition is associated with a U wave?

A

Hypokalemia

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20
Q

Peaked T waves can be caused by?

A

MI, Hyperkalemia, Intracranial bleed

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21
Q

ST elevation or depression greater than____mm, can be an MI?

A

1mm

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22
Q

Hypercalcemia and hypocalcemia what is seen on EKG?

A

Hyper - Shorted QT
Hypo - Long QT

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23
Q

Which limb leads monitor the inferior wall of the heart?

A

II, III, aVF

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24
Q

Which limb leads monitor the later side of the heart?

A

I, aVL, V5, V6

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25
Q

Which limb leads monitor the LAD septum?

A

V1, V2

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26
Q

Which limb leads monitor the LAD anterior?

A

V3, V4

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27
Q

What is the normal axis degree numbers?

A

Between -30 and +90

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28
Q

If the axis is more negative, that means what type of deviation?

A

Left

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29
Q

If the axis is more positive, that means what type of deviation?

A

Right

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30
Q

What two things can cause a Sinus arrythmia?

A

-Breathing
–Inhale faster HR
–Exhale slower HR

-Bainbridge reflex

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31
Q

What is the first line of treatment for bradycardia? Dosage?

A

Atropine but if less than 0.5 can cause paradoxical bradycardia through the muscarinic receptors

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32
Q

What should severely symptomatic bradycardic patients receive?

A

Pacing

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33
Q

How does glucagon work?

A

Increasing cAMP

Helpful in CCB and BB overdose

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34
Q

How does sinus tachycardia affect the heart?

A

Increases O2 consumption while decreasing supply

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35
Q

What must be performed with new AFIB or Aflutter older than 48 hours?

A

TEE

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36
Q

Should you cancel surgery with new AFIB or Aflutter?

A

Yes

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37
Q

What is the most common postoperative tachyarrhythmias?

A

AFIB

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38
Q

Is afib or aflutter organized?

A

Aflutter with a rate of 250-300

Not all signals get past the AV node

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39
Q

Treatment for Aflutter?

A

Cardioversion at 50 J

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40
Q

Where do PVC originate from? What causes them?

A

AV node

Many things -

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41
Q

When and how should PVCs be treated?

A

When they are frequent (>6 a minute)

-Reverse the underlying cause
-Treat with lidocaine 1mg/kg

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42
Q

What is Brugada syndrome

A

Sodium channel issue

Causes nocturnal death in Asian men

Can be seen on V1-V3 and need ICD

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43
Q

What heart blocks affect the AV node? treatment?

A

Type 1
Type 2 I (longer longer, drop)

Monitor

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44
Q

What heart block affects the bundle branches?

A

Type 2 II (random p drops)

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45
Q

What heart block has degeneration of the atrial conduction system? (Lenegre’s)

A

Type 3

Need to pace or isoproterenol

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46
Q

How does adenosine work? Half life?

A

Slows conduction through the AV node by stimulating the adenosine receptor and inhibits K channels

Hyperpolarizes the membrane

5 second half life

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47
Q

When is adenosine helpful? Not?
What can it cause?

A

Good for SVT and WPW

Bad for afib, aflutter, vtach

Bronchospasm in asthmatic patients

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48
Q

Dosage for adenosine for peripheral and central?

A

P -6mg then 12

C-3mg then 6

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49
Q

What is the most common cause of tachyarrhythmias?

A

Reentry pathways

(backwards movement of electrical impulse)

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50
Q

How to stop a reentry pathway?

A

Break the circuit
1. Slow conduction velocity
2. Increase refractory period

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51
Q

Examples of a reentry pathway where velocity is too slow?

A

Ischemia
Hyperkalemia

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52
Q

Examples of a reentry pathway where refractory period is shorter?

A

Epi
Electric shock

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53
Q

Examples of a reentry pathway where it occurs over a long distance?

A

Left atrial dilation to mitral stenosis

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54
Q

What is WPW?

A

Most common pre-excitement syndrome

Direct communication between atria and ventricle

Seen with Delta wave

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55
Q

What are two ways WPW can be classified ? Which is most common? What is more dangerous?

A

Orthodromic and antidromic

Common-Orthodromic

Dangerous - Antidromic

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56
Q

Which AVRNT has a narrow QRS and a wide QRS?

A

Ortho- Narrow
Anti- Wide

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57
Q

What are two safe options for both AVRNT?

A

Amio and cardioversion

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58
Q

What are the only three things for antidromic treatment?

A

Amio
Cardioversion
-Procainamide

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59
Q

What is the treatment for WPW combined with afib?

A

Procainamide

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60
Q

Definitive treatment for WPW? What must be monitored?

A

Ablation

Esophageal temp

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61
Q

Treatment for torsades?

A

Mag
Pacing
Avoid SNS stimulation

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62
Q

What does DDD mean on a pacemaker?

A

Dual Paced
Dual Sensed
Dual triggered and inhibited

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63
Q

What does AOO mean on a paceaker?

A

Atrial paced
No sense
No response to native cardiac activity

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64
Q

What does VVI mean on a pacemaker?

A

Ventricular paced
Ventricular sensed
I tells pacemaker not to fire if electrical activity is seen

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65
Q

What 3 things cause a pacemaker to fail?

A
  1. Pulse generator failure
  2. Lead failure
  3. Failure to capture
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66
Q

What can impair a pacemaker?

A

Electrocautery and radiofrequency ablation

Bipolar is much better

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67
Q

MRI with a pacemaker?

A

Contradicted

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68
Q

What is the most important thing to know about pacemakers?

A

The underlying rhythm so you know how to treat

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69
Q

What happens when a magnet is placed on a pacemaker?

A

Goes to asynchronous mode

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70
Q

What happens when a magnet is placed on a ICD?

A

Suspends the shock

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71
Q

What happens when a magnet is placed on a pacemaker and ICD?

A

Suspends ICD but not the pacemaker

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72
Q

What is seen after a PAC?

A

Non compensatory pause

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73
Q

In Aflutter, does every atrial depolarization have a contraction?

A

Yes

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74
Q

What two syndromes are associated with prolonged QT?

A

Timothy and Romano Ward

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75
Q

What does cerebral oximetry monitor?

A

Global oxygenation of VENOUS blood.

75% of blood in the brain is venous

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76
Q

What percentage change suggests a reduction in cerebral oxygenation? What can contaminate the signal

A

> 25%

Scalp hypoxia can throw off numbers

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77
Q

How do brain waves change during anesthesia?

A

Induction and light anesthesia increases beta waves

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78
Q

What produces burst suppression?

A

Deep anesthesia

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79
Q

At what MAC level can cause complete suppression of Isoelectricity?

A

1.5-2.0

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80
Q

Which anesthetic gas can produce beta waves?

A

N2O

81
Q

Which anesthetic gas can produce seizures?

A

Sevo

82
Q

Which drug can cause myoclonus but not associated with epilepsy

A

Etomidate

83
Q

Which drug can falsely elevate EEG?

A

Ketamine

84
Q

When else can burst suppression occur?

A

Hypothermia, CPB

85
Q

What is unilateral burst suppression suggestive of?

A

Cerebral ischemia

86
Q

What are the order of brain waves?

A

Beta
Alpha
Theta
Delta
Burst suppression
Isoelectricity

87
Q

Which brain wave is associated with GA, hypothermia, CPB, and ischemia?

A

Burst suppression

88
Q

Which brain wave is associated with GA and children sleep?

A

Theta

89
Q

Which brain wave is associated with GA, deep sleep, and brain injury?

A

Delta

90
Q

Which brain wave is associated with awake mental stimulation and light anesthesia?

A

Beta

91
Q

Which brain wave is associated with awake but restful sleep with eyes closed?

A

Alpha

92
Q

When happens to brain waves as the anesthesia becomes deeper?

A

Lower frequency and higher amplitude

93
Q

What two things can interfere with BIS?

A

Nitrous and Ketamine

94
Q

What is the time delay of BIS?

A

20 seconds

95
Q

When also is BIS less accurate?

A

Children, hypothermia, increased muscle tone, encephalopathy

96
Q

Which law does electricity follow ?

A

Ohm’s law

Voltage - driving pressure
Current - Flow
Impedance - Resistance

97
Q

What is the maximum allowable current leak in the OR? When does Vfib occur?

A

10 uA

100 uA

98
Q

Is the OR power supply grounded?

A

NO

99
Q

Is the equipment in the OR grounded?

A

YES

100
Q

What is the Line isolation monitor?

A

It tells you when the OR BECOMES GROUNDED

101
Q

Does the Line isolation monitor protect you?

A

No it is just alarm when a leak of 2-5 mA is detected

102
Q

What is a grounding pad?

A

Provides an exit point for electricity on the patient.

IT DOES NOT GROUND THE PATIENT

103
Q

What do you do if there is exhaustion of the CO2 absorbent?

A

Increases FGF to 5-8
TIVA

Do not increase the MV because it will not fix the issue

104
Q

If increasing FGF does not fix the problem, what is likely the issue?

A

Incompetent unidirectional valve

105
Q

What components are not present in a Mapleson circuit?

A

Unidirectional valves
CO2 absorber

106
Q

Advantages of a Mapleson?

A

Less airway resistance (good for peds)

Convenient

Easily scavenged

Bain circuit prevents heat loss

107
Q

What is the pethick test?

A

A test for the integrity if the inner tubing on the Bain circuit

108
Q

Which Mapleson is best for spontaneous ? Worst?

A

Best - A (spontAneous)

Worst - B

109
Q

Which Mapleson is best for cmv ? Worst?

A

Best- D (controlleD)

Worst - A

110
Q

How much FGF is required when using a Mapleson?

A

2.5 x minute ventilation

Mapleson A needs 20L/min

111
Q

What is the Bain system good for?

A

Modified Mapleson D

Has thin inner tubing and the gas is warmed through the corrugated tubing around it

112
Q

How is the Pethick test performed?

A

-Occlude the elbow
-Close APL
-Flush with O2
-Remove occlusion while flushing

**if the bag deflates it is okay to use

***if the bag stays inflated, NOT okay

113
Q

Which Mapleson circuits are most likely to be seen today?

A

D,E,F

114
Q

How is compiance measured?

A

Change in Volume / Change in Pressure

115
Q

What is compliance influenced by?

A

Muscle tone
Degree of lung inflation
Alveolar surface tension
Interstitial lung water
Pulmonary fibrosis

116
Q

What is dynamic compliance?

A

Movement of lungs

117
Q

What is static compliance ?

A

Lungs are not moving

118
Q

When is plateau pressure measured?

A

-During static (no airflow)
-Barotrauma when pressure exceeds 35

119
Q

What is a normal Alpha angle? What conditions cause in increase?

A

100-110 degrees
**obstruction

COPD, Kink, bronchospasm

120
Q

What may be the cause of increased beta angle?

A

Falty unidirectional valve

121
Q

What is the PaO2 if the SpO2 reads 90?

A

60 - 30 point difference

122
Q

What site is the fastest response for a SpO2? Slowest?

A

Fastest - Head
Middle - Finger
Slowest-Toe

123
Q

Inline(Main stream) end tidal is useful for ?

A

Fast response
Increases Dead space
Doesn’t require a pump or trap

124
Q

Side stream (diverting) is useful when?

A

Outside the airway
Requires pump/water trap
Slower response time

125
Q

What two wavelengths does a pulse emit?

A

940 - near infrared(arterial,oxy)
660- Red light (Venous,deoxy)

126
Q

What shifts to L on the oxyhemoglobin curve?

A

Decreased everything and alkalosis

127
Q

What shifts to R on the oxyhemoglobin curve?

A

Increased everything and acidosis

128
Q

What does the pulse ox monitor ? (3 things)

What does it not?

A
  1. Hgb saturation
  2. HR
  3. Fluid responsiveness

**Does not measure anemia or ventilation

129
Q

What is methemoglobin?

A

Equal light at 660 and 940

Pulse ox will read 85%

Could be higher or lower

130
Q

What is carboxyhemoglobin?

A

Absorbs at 660

So it overestimates SpO2

May say 99% when it really is 80%

131
Q

Which factors do not affect pulse ox?

A

Hgb S
Hgb F
Jaundice
Fluorescein
Polycythemia
Acrylic nails

132
Q

How is all gas analyzed on all modern machines?

A

Infrared spectrophotometry

O2 is by galvanic cell or paramagnetic

133
Q

What is the ideal length of the bladder on a BP cuff?

A

80% circumference

134
Q

What is the ideal width of the bladder on a BP cuff?

A

40%

135
Q

Where is the narrowest PP?

A

At the artic root
SBP is lowest and DBP is highest

136
Q

Where is the widest PPV?

A

Foot

137
Q

If the BP cuff is above the heart will the reading by falsely high or low?

A

Falsely low

138
Q

How much does BP change for every 10cm? every inch?

A

10cm = 7.4mmhg

1inch= 2mmhg

139
Q

How many oscillations are appropriate for an optimally damped Art line?

A

1

140
Q

How many oscillations are seen for an under damped Art line?

A

many bounces

SBP is overestimated and DBP is under

141
Q

How many oscillations are seen for a over damped Art line?

A

None

SBP is underestimated, DBP is over

142
Q

Examples of an overdamped Art line?

A

Air bubble
Clot
No pressure

143
Q

Examples of under dampened Art Line?

A

Stiff tubing
Catheter whip

144
Q

Is the MAP accurate with an over or under dampened art line?

A

Yes

145
Q

Distance from insertion site for
Subclavian
R IJ
L IJ
Femoral
Basilic

A

Subclavian - 10 cm
R IJ - 15 cm
Left IJ - 20 cm
Femoral - 40 cm
Basilic - 45

146
Q

Distance through heart?
RA
RV
PA
PAOP

A

RA 0-10cm
RV 10-15cm
PA 15-30cm
PAOP 25-25cm

147
Q

Where should a CVP catheter reside? PA catheter?

A

CVP - Junction of the vena cava and RA (**NOT INSIDE)

RA - in the PA

148
Q

When does infection risk increase for central lines?

A

After three days

149
Q

What is at risk for obtaining an L IJ?

A

Thoracic duct puncture resulting in chylothorax

150
Q

Should you advance a PA if the patient has a LBBB?

A

NO, advancing may result in a RBBB which leads to complete heart block

151
Q

Classic sign of a pulmonary artery rupture?

A

Hemoptysis

152
Q

What three things increases risk of a PA rupture?

A

-Hypothermia
-Anticoagulation
-Advanced age

153
Q

What is the a wave on a CVP?

A

Right atrial contraction

(Just after the P wave on an EKG)

154
Q

What is the C wave on a CVP?

A

Right ventricle contraction (the bulging of the tricuspid into the TA)

Just after the QRS on an EKG

155
Q

What is the X descent on a CVP?

A

RA relaxation

ST segment on EKG

156
Q

What is the V wave on the CVP?

A

Passive RA filling

Just after the T wave begins on a EKG

157
Q

What is the y descent on an CVP?

A

RA empties through a open tricuspid valve

After the T wave ends

158
Q

What should Right atrial pressure equal?

A

Left ventricle end diastolic pressure

159
Q

What might it mean if the A wave is loss on a CVP?

A

Atrial contraction is lost

Afib
V pacing

160
Q

What might a large A wave mean?

A

High pressure or resistance

Lung disease
Diastolic dysfunction
Tricuspid stenosis
MI
AV issues

161
Q

What might a large V wave signal?

A

-Tricuspid regurg
-Acute Increase in intravascular volume
-RV papillary ischemia

162
Q

Normal RA pressure?

A

1-10

163
Q

Normal Right ventricle pressure?

A

15-30

and

0-8

*Diastolic is equal to cvp

164
Q

Normal PA pressure? Waveform?

A

25/10

Waveform looks just like A line

165
Q

Normal PAOP? Waveform?

A

5-15

Just like a CVP waveform

166
Q

What zone should the PAC be in?

A

Zone III since there is a continuous column of blood

Zone III is the dependent region

Pa>Pv>PA

167
Q

How can you tell the PA tip is NOT in west zone III?

A
  1. Nonphasic tracing
  2. PAOP > PA end diastolic rescuer
  3. Cannot aspirate blood from the distal port
168
Q

Conditions where PAOP underestimates LVEDV?

A

Aortic regurg

169
Q

How is thermodilution done?

A

5% dextrose and NS are injected through the proximal port.

If the fluid rapidly travels then the CO is high and if it takes longer then the CO is low

170
Q

What are the 4 variables to Mixed venous saturation?

A

Q=CO
VO2=O2 consumption
Hgb
SaO2

171
Q

Why is a PA required to measure SvO2?

A

Need to measure all blood returning to the heart

SVC
IVC
Coronary Sinus

172
Q

Distance for R subclavian, R IJ, L IJ?

Distance for PA through heart?

A

R sub - 10cm
R IJ - 15cm
L IJ - 20

RA - 10
RV - 15
PA - 20
Wedge - 30

173
Q

When should CVP be measured?

A

End expiration

174
Q

What is seen on the PA waveform when the PA enters the PA?

A

Diacrotic notch
Increased in diastolic BP

175
Q

When does PAOP overestimate LVEDP?

A

PEEP and diastolic dysfunction

176
Q

When does PAOP underestimate LVEDP?

A

Aortic insufficiency

177
Q

How does a high injectate volume effect CO? Low volume?

A

High volume = underestimates
Low volume = overestimates

178
Q

Can you accurately measure CO with a R to L shunt?

A

No

179
Q

How does warm injectate and a partially wedged catheter effect CO?

A

over estimates

180
Q

When should thermodilution be used over continuous CO? Why?

A

Unstable patients because continuous monitoring has a delay

180
Q

How does hypothermia effect SVO2?

A

Increases SvO2

181
Q

How does fever effect SVO2?

A

Decreases

182
Q

How does cyanide toxicity effect SVO2?

A

Increases

183
Q

How does anemia effect SVO2?

A

Decrease

184
Q

How does RBC infusion effect SVO2?

A

Increases

185
Q

How does shivering and pain effect SVO2?

A

Decreases

186
Q

How does hypoxemia effect SVO2?

A

Decreases

187
Q

How does thyroid storm effect SVO2?

A

Decreases

188
Q

How does increased CO effect SVO2?

A

Increases

189
Q

What is a normal SVO2?

A

65-75%

190
Q

When assessing fluid responsiveness, how much should stroke volume increase when a 250mL bolus is given ?

A

10%

191
Q

How does increased LV filling effect stroke volume? Decreased filling?

A

Increased filling = larger stroke volume (Starling mechanism)

Decreased filling = Smaller stroke volume

192
Q

Howd does a positive pressure breath effect LV filling?

A

Augments LV filling, Decreases RV filling

193
Q

Should you use an esophageal doppler with esophageal disease? Will it effect the values?

A

Do not use but won’t effect the value if used

194
Q

What varibles will affect esophageal doppler?

A

Any issues with the aorta, pregnancy, CPB

195
Q

An esophageal doppler, when medicine is given to increase the width of the triangle?

A

Fluid, by giving fluid the it will become wider

196
Q

An esophageal doppler, when medicine is given to increase the height of the triangle?

A

Vasodilator

197
Q

An esophageal doppler, when medicine is given to increase the height and decrease the width of the triangle?

A

Inotrope

198
Q

What conditions increased pulmonary resistance?

A

kinked tube
ET cuff herniation
Foreign body
Compression of airway
bronchospasm
bronchial secretions

Monitoring (10 decks)

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