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Clinical Methods 2 > Pulmonary Diseases & Axis, Hypertropy, Enlargement > Flashcards

Pulmonary Diseases & Axis, Hypertropy, Enlargement Flashcards

1
Q

Pulmonary embolism is a blockage of the ________ and is most likely caused by blood clots that travel to the ______ from another part of the body (most commonly the legs). In short, a PE is a complication of a _________.

A

pulmonary artery lungs DVT

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2
Q

What are the risk factors(3) for PE?

A

Venous stasis (immobility, reduced flow) Abnormal vessels/wall injury (trauma, phlebitis) Hypercoagulability (polycythemia, sickle cell, smoking, pregnancy)

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3
Q

What are the 9 clinical manifestations of Pulmonary Embolism?

A
  • Acute dyspnea
  • Tachypnea (>20 RR)
  • Pleuritic chest pain
  • Nonproductive cough
  • Accentuation of pulmonic valve (S2)
  • Rales
  • Tachycardia (>100 bpm)
  • Fever (38-39 deg C)
  • Hemoptysis
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4
Q

What 4 diagnostic tools/test used to detect a PE?

A
  • Perfusion lung scanning (V/Q scan)
  • Venous ultrasonography
  • Pulmonary angiography
  • Spiral CT scan
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5
Q

Perfusion lung scanning (V/Q scan):

A

Medical imaging using scintagraphy and medical isotopes to evaluate the circulation of air and blood within a pt. lungs, to determine the ventilation/perfusion ratio.

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6
Q

Venous ultrasonography:

A

Sonogram of the lower extremeties to evaluate DVT (normal results don’t exclude PE)

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7
Q

Pulmonary angiography:

A

Injection of radiocontrast into circulation with fluoroscopy of the lungs.

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8
Q

Spiral CT scan:

A

CT slices in a helical pattern for increase resolution

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9
Q

What 5 things should be considered for treating PE?

A
  • anticoagulant (heparin, coumadin)
  • Inotropes for hypotension (dopamine, dobutamine)
  • Airway management (intubate, MV w/ PEEP)
  • Analgesics
  • Pulmonary artery embolectomy w/ CPB (massive PE unresponsive to medical management)
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10
Q

Chronic obstructive pulmonary disease (COPD) encompasses__________ and ___________.

A

Obstructive bronchitis and emphysema

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11
Q

Chronic bronchitis is:

A
  • Cough due to hypersecretion of mucus not necessarily accompanied with airfflow limitation.
  • productive cough >3months in duration for >2 successive yrs.
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12
Q

Emphysema is characterized by:

A
  • loss of elastic recoil in the lungs
  • airway collapse occurs during exhalation, leading to increased airway resistance
  • severe dyspnea with use of accessory muscles
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13
Q

What 4 diagnostic tools can be used to detect COPD?

A
  • Physical exam: tachypnea, prolonged expiration w/ wheezing
  • Pulmonary Function tests
  • Chest Radiography
  • ABG
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14
Q

What are the preoperative, intraoperative, and postoperative anesthetic considerations for COPD patients?

A

Preoperative: cessation of smoking and eradicate bacterial infections Intraoperative: REGIONAL Anesth for procedures on the extremeties or don’t invade the peritoneum. GENERAL Anesth for upper abdominal & thoracic proc Postoperative:analgesia and lung vol expansion techniques

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15
Q

List 5 other causes for airflow obstruction:

A
  • Bronchiectasis
  • Csystic fibrosis (common genetic dz in caucasions)
  • Primary ciliary dyskinesia
  • Bronchiolitis Obliterans
  • Tracheal stenosis
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16
Q

Asthma is characterized by:

A

Chronic airway inflammation Reversible expiratory airflow obstruction Ariway (bronchial) hyperreactivity

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17
Q

T of F: Asthma is usually reversible.

A

True

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18
Q

What are the clinical manifestations of asthma?

A

Wheezing, cough, dyspnea

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19
Q

How do you treat Asthma?

A

Antiinflammatory drugs: corticosteroids, cromolyn, leukotriene inhibitors Bronchodilator drugs: B-Adrenergic agonists, anticholinergic drugs

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20
Q

What are the preoperative meds for asthma pts?

A

Bronchodilators: B-adrenergic agonists, anticholinergic drugs Avoid NSAIDs

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21
Q

What anesthetic considerations should you consider for ASTHMA pts during induction and maintenance?

A

Regional - when operative site is superficial or on extremeties General - adequate depth before DL (fentanyl, lidocaine, propofol-bronchodilating effects)

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22
Q

How do you treat intraoperative bronchospasm?

A

Increase depth and administer bronchodilator via ETT

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23
Q

What is Restrictive Lung Disease?

A

A decrease in total lung capacity usually caused by an intrinsic disease that alters the elastic properties of the lungs, causing the lungs to stiffen.

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24
Q

List 4 causes for acute restrictive lung disease (pulmonary edema):

A

Acute respiratory distress syndrome (ARDS), aspiration, upper airway obstruction, CHF

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25
Q

List 4 causes for Chronic intrinsic restrictive lung disease:

A

Sarcoidosis, hypersensitivity pneumonitis, drug-induced pulumonay fibrosis

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26
Q

List common causes for Chronic EXTRINSIC restrictive lung disease:

A

Obesity/ascites/pregnancy, deformities of skeletal structures/sternum, NM disorders (Guillan-Barre syndrome, Myasthenia gravis)

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27
Q

List 3 common causes of restrictive lung disease due to disorders of the pleura and mediastinum:

A

Pleural effusion, pneumothorax, mediastinal mass

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28
Q

What are the clinical manifestations of Restrictive lung disease?

A

Decreased VC Dyspnea Hypercarbia / arterial hypoxemia Weakness of expiratory muscles from NM dz

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29
Q

What diagnostic measurements are indicative of Restrictive Lung Dz?

A
  • FEV1/FVC > 80%

* TLC is 80% or less than expected value

30
Q

What other procedures can be performed to diagnose Restrictive Lung Dz?

A

Fiberoptic bronchoscopy, percutaneous needle biopsy, pleuroscopy, mediastinoscopy

31
Q

How do you treat Restrictive Lung Disease?

A

Corticosteroid, immunosuppressive agents, and cytotoxic agents are the mainstay of therapy for many of the interstitial lung diseases. Lung transplantation to those who are refractory to medical management.

32
Q

What are anesthetic considerations for pts with Restrictive Lung Disease?

A
  • Minimize ventilation depression
  • Regional for peripheal operations and sensory levels T10 and below
  • Post-operative mechanical ventilaion may be needed
33
Q

Define Acute Respiratory Failure:

A

Inability of the patient’s lung to provide adequate arterial oxygenation with or without acceptable elimination of CO2. Fatigue of the breathing muscles usually a factor.

34
Q

What is the criteria for Acute Respiratory Failure?

A
  • PaO2 < 60 mmHg (despite supplemental O2 in the absence of R-L intracardiac shunt)
  • PaCO2> 50mmHg (in the absence of respiratory compensation)
35
Q

How is Acute distinguished from Chronic Respiratory Failure?

A

By pH: 7.35-7.45 (normal) despite increased PaCO2 (I interpret the slide to mean ARF has normal pH range but this doesn’t seem right; so do more research to confirm)

I think this is right Marlon because ARF doesn’t have time to compensate, thus the pH would be in a normal range.

36
Q

List treatments for Acute Respiratory Failure (12):

A

Supplemental O2, Traheal intubation, Mech. Ventilation, PEEP, Optimize IV fluid volume, drug-induced diuresis, inotropic support, removal of secretions, control of infection, nutritional support, glucocoricoids?, and inhaled B-adrenergic agonists?

37
Q

Define Hypertrophy of the heart:

A
  • Refers to an increase in muscle mass
  • The wall of a hypertrophied ventricle is thick and poweful Caused by a pressure overload in which the ventricle pumps against increased resistance (HTN & aortic stenosis)
38
Q

Define Enlargement of the heart:

A
  • Refers to dilation of a particular chamber Typically caused by volume overload in which the chamber dilates to accomodate an increased amount of blood as a result of valvular insufficiency (AR and MR)
39
Q

Which EKG wave do we use to assess atrial enlargement?

A

P-Wave

40
Q

Which EKG signal can be used to assess ventricular hypertrophy?

A

QRS complex

41
Q

List 3 ways an EKG can change when a chamber enlarges or hypertrophies:

A
  • The chamber can take longer to depolarize so the EKG may increase in duration
  • The chamber can generate more current and thus a larger voltage so the the wave may increase in amplitude
  • A large % of the total electrical current can move through the expanded chamber so the mean electrical vector (axis) may shift
42
Q

How can you quickly determine if the QRS axis is normal?

A

If the QRS is positive in leads I and AVF, then the QRS axis is normal.

43
Q

A normal QRS axis lies between ____ and ____ degrees.

A

0 and +90 deg

44
Q

Define the term axis.

A

Refers to the direction of mean electrical vector, representing the average direction of flow. Defined in the frontal plane only.

45
Q

Describe the 3 steps to determine the QRS axis.

A
  • Find the lead where the QRS complex is most nearly biphasic.
  • The axis must then be oriented approximately perpendicular to that axis.
  • A quick estimate can be made by looking at leads I and AVF (normal if both are positive)
46
Q

Normal QRS axis =

A

0 to +90 deg (Leads I + and AVF +)

47
Q

Right Axis Deviation (RAD) =

A

90 to 180 deg (Leads I- and AVF +)

48
Q

Left Axis Deviation (LAD) =

A

0 to -90 deg (Leads I+ and AVF -)

49
Q

Extreme Rigt Axis Deviation =

A

-90 to 180 deg (Leads I- and AVF -)

50
Q

A normal p-wave is ___ sec in duration and the largest deflection (+ or -) should not exceed ___mm

A

< 0.12

2.5mm

51
Q

The first half of the p wave represents _______ and the second half represents __________.

A

right atrial depolarization left atrial depolarization

52
Q

Atrial enlargement is assessed in which two leads?

A

Leads II and V1

53
Q

Define Lead II:

A

Lead II is oriented parallel to the flow of current through the atria (parallel to the mean p wave vector/largest positive deflection)

54
Q

Define Lead V1:

A

Lead V1 is oriented perpendicular to the flow of current (biphasic-easy separation fo the right and left atrial components)

55
Q

Right Atrial Enlargement is also called ____.

A

P pulmonale b/c it is often caused by severe lung disease.

56
Q

Right atrial enlargement (RAE) can quickly be diagnosed by the presence fo tall P waves in which leads?

A

Leads II, III, and AVF

57
Q

Left atrial enlargement indicated by what changes in the EKG?

A

2nd portion of p wave may increase in amplitude

58
Q

The diagnosis of left atrial enlargement requires that the terminal (LA portion) of the p wave should do what in V1?

A

drop at least 1 mm below the isoelectric line in V1

59
Q

There is a more prominent increase in duration in the p wave (because this can be demonstrated in LA which is last to depolarize). True or false?

A

true

60
Q

Left atrial enlargement is also known as:

A

P mitrale because mitral disease is a common cause of LAE

61
Q

In RAE, there is no change in p wave duration. True or false?

A

true

62
Q

In RAE, there is a possible right axis deviation of the p wave. True or false?

A

true

63
Q

To diagnose LAE, there are 3 changes to observe. Name them.

A

1) the amplitude of the terminal component of the p wave may by increased and must descend at least 1 mm below the isoelectric line in V1.
2) duration of p wave is increased
3) no significant axis deviation is seen b/c the LA is normally electrically dominant.

64
Q

In right ventricular hypertrophy, the most common feature is what?

A

is right axis deviation (nl axis between 0-90 veers to between 90-180

65
Q

What will you also notice will change in EKG for right ventricular hypertrophy?

A

QRS complex in lead I (0 degrees) must be slightly more negative than positive

66
Q

What will you notice change on EKG in precordial leads for left ventricular hypertrophy?

A

*R wave amplitude in lead V5 or V6 plus the S wave amplitude in lead V1 or V2
exceeds 35 mm.

67
Q

What will you notice change on EKG in limb lead for left ventricular hypertrophy?

A

*The R wave amplitude in lead AVL exceeds 13 mm

68
Q

The R wave is larger than the S wave in V1, whereas the S wave is larger than the R wave in V6 indicates what heart condition?

A

right ventricular hypertrophy

69
Q

The R wave in V5 or V6 plus the S wave in V1 or V2 exceeds 35 mm

A

left ventricular hypertrophy

70
Q

Asymmetric T wave inversion and downsloping ST segment depression

A

secondary repolarization abnormalities

Clinical Methods 2 (11 decks)

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