TEST 2 Flashcards
What are the ribs numbered 1-7 known as?
True ribs
True ribs attach directly to the sternum by costal cartilage.
How do ribs 8, 9, and 10 attach to the sternum?
Attach to the costal cartilage above
These ribs are not directly attached to the sternum.
What is the classification of ribs 11 and 12?
Free-floating ribs
Their tips can be palpated.
What is the Angle of Louis?
The junction between the manubrium and the body of the sternum
It serves as an anatomical landmark.
At which rib level is the Angle of Louis located?
Level of the 2nd rib
It helps to identify various anatomical structures.
What anatomical structures can be identified using the Angle of Louis?
- Tracheal bifurcation (carina)
- Aortic arch
- Upper border of atria of the heart
- Above T4-T5 intervertebral disc level
These landmarks are crucial for anatomical orientation.
What is the normal anterior to posterior (AP) to transverse diameter ratio of the thoracic cage?
0.70 – 0.75
This ratio is important for assessing thoracic shape.
What are the three types of breath sounds?
- Bronchial Sounds
- Bronchovesicular Sounds
- Vesicular Sounds
Each type is associated with different anatomical locations and characteristics.
Describe Bronchial Sounds.
Normal over the trachea, loud/harsh with midrange pitch & intensity (expiration)
These sounds indicate airflow through larger airways.
Where are Bronchovesicular Sounds typically heard?
Over major bronchi (anterior upper 1/3 of chest)
They are medium-pitched and can be heard during both inspiration and expiration.
What characterizes Vesicular Sounds?
Low-pitched, soft, heard over peripheral lung fields (inspiration/posterior bases)
These sounds indicate normal airflow in the alveoli.
What is Tactile Fremitus?
The palpable vibration felt on the chest when a patient speaks
It helps assess lung conditions.
What does increased fremitus suggest?
Lung consolidation (e.g., pneumonia)
This indicates denser lung tissue.
What does decreased fremitus indicate?
Pleural effusion, pneumothorax, or obesity
These conditions result in less dense lung tissue.
What is Rhonical fremitus?
Palpable vibration produced during breathing caused by partial airway obstruction
It indicates an obstruction in the airways.
What does pleural friction sound like?
An audible raspy breathing sound
It is often associated with pleuritis.
What is the length of the trachea in adults?
10 to 11 cm
How does the right main bronchus compare to the left main bronchus?
Shorter, wider, and more vertical
What is the role of the trachea and bronchi?
Transport gases between the environment and lung parenchyma
What constitutes dead space in the respiratory system?
150 ml in adults
What protects alveoli from small particulate matter in inhaled air?
Bronchial tree
What type of cells line the bronchi and secrete mucus?
Goblet cells
What is the Acinus?
The functional unit of the lung responsible for gas exchange
What are the components of the Acinus?
- Respiratory Bronchioles
- Alveolar Ducts
- Alveolar Sacs
- Capillary Network
What is the age at which infants are obligate nose breathers?
Until 3 months
By how much does tidal volume increase during pregnancy?
40%
Patients with COPD are how many times more likely to have postoperative pulmonary complications?
2 times
What are some risk factors for surgical pulmonary complications?
- Preop sepsis
- Emergency operations
- > 50 years old
- Smoking
- COPD
- OSA
- Preop weight loss
- Obesity
- Upper respiratory infection
- Type of surgery
- Length of surgery
- Elevated creatinine
What is a common surgical pulmonary complication characterized by alveolar collapse?
Atelectasis
What causes pneumonia as a surgical pulmonary complication?
Infection due to retained secretions, immobility, or aspiration
What leads to pulmonary embolism (PE)?
Clot migration leading to sudden hypoxia and respiratory distress
What is bronchospasm?
Increased airway resistance due to irritation from intubation or underlying conditions like asthma
What does ARDS stand for?
Acute Respiratory Distress Syndrome
What is a risk associated with ARDS?
Severe inflammatory lung injury leading to hypoxia
What are other causes of surgical pulmonary complications related to perioperative events?
- Micro aspiration
- Excessive administration of fluids/blood products
- Systemic inflammatory response
- Immunosuppression
What is the ARISCAT score used for?
Predicts overall risk of postoperative pulmonary complications (PPC)
What are the risk levels indicated by the ARISCAT score?
- Low
- Intermediate
- High
What is Obstructive Sleep Apnea (OSA)?
OSA is characterized by repetitive airway collapse during sleep, causing intermittent hypoxia and disrupted sleep cycles.
Most prevalent sleep disorder affecting 9-25% of the general population, with a large portion undiagnosed.
What are the standard screening tools for OSA?
Screening pre-operatively is the standard with post-operative monitoring, including:
* STOP-Bang
* P-SAP
* Berlin
* ASA checklist
STOP-Bang: >3 predicts some type of sleep apnea.
What are the risk factors for Obstructive Sleep Apnea?
Risk factors include:
* Obesity
* Large neck circumference
* Anatomical airway obstruction (e.g., enlarged tonsils, retrognathia)
* Male gender
* Older age
What is the primary diagnostic tool for OSA?
Polysomnography (Sleep Study): Monitors apneic/hypopneic episodes, oxygen saturation, and sleep disturbances.
Apnea must last 10 seconds or greater with a saturation drop by 3-4%.
How is the Apnea-Hypopnea Index (AHI) classified?
AHI Classification:
* Mild: 5-15 events/hour
* Moderate: 15-30 events/hour
* Severe: >30 events/hour
What is the gold standard therapy for OSA?
CPAP (Continuous Positive Airway Pressure) is the gold standard therapy.
What non-surgical treatment can help reduce airway obstruction in OSA?
Weight loss helps reduce airway obstruction.
What surgical interventions are available for severe cases of OSA?
Surgical interventions include:
* Uvulopalatopharyngoplasty (UPPP)
* Maxillomandibular advancement
What is the first principle of reading CXRs?
Always follow a structured method for reading CXRs.
A systematic approach is crucial for accurate interpretation.
What should be compared when assessing CXRs?
Compare with previous CXRs to assess for changes.
This helps in identifying any new or evolving pathologies.
Which elements are key to assess in CXRs?
Name/Marker/Rotation/Penetration, Lines/Metal Work, Heart, Mediastinum, Lungs, Bones, Diaphragm, Soft Tissues.
Never Make Really Paranoid Lawyers Miss Highly Major Lawsuits, Because Dumb Stuff
What should be assessed about the clavicles in a CXR?
Clavicles should be equidistant from the spinous processes of the thoracic spine.
This indicates proper rotation and positioning.
What indicates a prior thoracic surgery on a CXR?
Sternal wires.
Their presence is a key marker in evaluating the patient’s surgical history.
Where should the endotracheal tube tip be located?
Approximately 2 cm above the carina.
Proper placement is crucial to ensure effective ventilation.
What is the maximum heart size in a standard PA erect view?
Heart should occupy no more than 50% of the maximum internal thoracic diameter.
Enlarged heart size may indicate cardiomegaly.
How can heart size be inaccurately assessed?
Cannot accurately assess heart size on an AP view due to magnification effects.
AP views often exaggerate the size of the heart.
What should be evaluated in the lungs during a CXR assessment?
Evaluate each lung zone (upper, middle, lower) separately and compare both sides for symmetry.
This helps in identifying localized pathologies.
What should be checked regarding the diaphragm in a CXR?
Both diaphragms should form a clear, sharp margin with the lateral chest wall.
Clear contours indicate normal diaphragm positioning.
What are common pathologies identified on CXR?
Atelectasis, Pleural Effusion, Pneumonia, Pneumothorax, Pulmonary Edema, ARDS, Cardiomegaly.
Each pathology has distinct radiographic features.
What does atelectasis appear as on a CXR?
Increased opacity due to lung collapse.
This can indicate a need for further evaluation or intervention.
What are signs of pleural effusion on a CXR?
Blunting of costophrenic angles due to fluid accumulation.
Recognizing this can guide further diagnostic imaging.
What does pneumonia look like on a CXR?
Patchy or consolidated fluffy opacities.
The pattern varies depending on the type of pneumonia.
What indicates pneumothorax on a CXR?
Air in the pleural space, causing lung collapse.
This is a critical emergency that requires immediate attention.
What does ARDS show on a CXR?
Diffuse bilateral opacities and loss of lung volume.
This finding often indicates severe respiratory distress.
What is a sign of cardiomegaly on a CXR?
Heart size >50% of the thoracic width (on PA film).
This may suggest underlying heart disease.
Where should the ET tube be positioned to avoid complications?
Ensure it is ~2 cm above the carina.
Incorrect placement can lead to lung collapse.
What is a consequence of right mainstem intubation?
ET tube too deep, causing left lung collapse.
This is a critical error that can severely affect ventilation.
Where should the NG tube be positioned?
In the distal esophagus.
Proper placement is essential for feeding and preventing aspiration.
What should be assessed for central line placements?
Ensure proper termination at the superior vena cava and avoid malposition.
Misplacement can lead to serious complications.
What are common symptoms of asthma?
Wheezing, shortness of breath, cough (worse at night/early morning)
Symptoms triggered by allergens, exercise, cold air, and infections
What are the key pathological features of asthma?
Chronic airway inflammation, increased bronchial smooth muscle mass, mucus hypersecretion, luminal narrowing
These features contribute to airway obstruction and hyperreactivity.
What spirometry finding is diagnostic for asthma?
FEV1/FVC ratio <70% (obstructive pattern)
Reversible obstruction is indicated by FEV1 increasing ≥12% after bronchodilator.
What is the purpose of bronchoprovocation testing in asthma?
Used if spirometry is inconclusive
Methacholine challenge test (FEV1 drops >20% = positive).
What are signs that asthma is not controlled?
- Symptoms >2 days/week
- Weekly nighttime awakening
- Limitation in normal activity
- Use of SABA >2 days/week
- FEV1 or Peak expiratory flow rate <80% predicted/goal
- > /= exacerbations requiring systemic glucocorticoids in the last year
These indicators help assess asthma control and management needs.
When might testing be necessary in COPD?
Changes in condition, intrathoracic surgery
Testing may be helpful to evaluate respiratory status.
What is the role of ABG’s in COPD management?
Helpful in suspected hypoxemia, suspected hypercapnia, when post-op ventilator management is likely
ABG’s can influence perioperative management.
When is a chest X-Ray considered for COPD patients?
Not routine, but may consider if:
* Changes noted from baseline
* Comorbid cardiac and respiratory problems
* Major intrathoracic or intrabdominal surgeries
Look for specific perioperative concerns like bullae or large air pockets.
What is the GOLD classification for COPD Stage 1?
Mild: FEV1 ≥80% predicted
This stage indicates a mild obstruction.
What is the GOLD classification for COPD Stage 2?
Moderate: FEV1 50-80% predicted
Patients may experience more noticeable symptoms.
What defines GOLD classification Stage 3 for COPD?
Severe: FEV1 30-50% predicted
Patients often have significant limitations in physical activity.
What is the criteria for GOLD classification Stage 4 COPD?
Very Severe: FEV1 <30% predicted or chronic respiratory failure
This stage indicates life-threatening respiratory failure.
What is the New York Heart Association (NYHA) Class I classification for heart disease?
No symptoms with normal activity.
This classification indicates that patients do not experience any limitations in their physical activities.
What are the symptoms associated with NYHA Class II heart disease?
Mild symptoms with normal activity.
Patients may experience slight limitations during physical activities.
What characterizes NYHA Class III heart disease?
Marked limitation with normal activity; comfortable at rest.
Patients find physical activities significantly challenging but can rest without symptoms.
What is the NYHA Class IV classification for heart disease?
Symptoms at rest, unable to perform any physical activity.
This indicates severe heart disease with debilitating symptoms.
What is restrictive lung disease?
Inflammation, fibrosis of lung parenchyma & decreased distensibility/recoil of lungs.
It leads to progressive dyspnea on exertion and a non-productive cough.
What are common causes of intrinsic restrictive lung disease?
- Pulmonary fibrosis
- Sarcoidosis
- Pneumonitis
These conditions primarily affect lung parenchyma.
What are some extrinsic causes of restrictive lung disease?
- Obesity
- Scoliosis
- Myasthenia gravis
- Diaphragmatic paralysis
- Ankylosing spondylitis
These conditions affect the chest wall or neuromuscular function.
Which neuromuscular disorders can cause restrictive lung disease?
- Myasthenia gravis
- Guillain-Barre syndrome
- Muscular dystrophies
These disorders impact muscle strength and control, leading to breathing difficulties.
What are the PFT findings indicative of restrictive lung disease?
- Decreased TLC
- Decreased FVC
- Decreased FEV1
- Normal or increased FEV1/FVC ratio (>80%)
- Low Diffusion Capacity (DLCO) in interstitial lung disease
These findings help differentiate restrictive lung disease from other types.
What characterizes obstructive lung disease in PFT results?
- Decreased FEV1
- Normal or decreased FVC
- Decreased FEV1/FVC ratio (<70-80)
Conditions like asthma, chronic bronchitis, and emphysema are examples of obstructive lung diseases.
Describe the normal flow volume loop.
Rapid peak expiratory flow (PEF) with gradual descent.
This indicates healthy lung function with no obstruction.
What does an obstructive pattern in a flow volume loop look like?
Scooped-out appearance due to prolonged exhalation.
This pattern is commonly seen in asthma and COPD.
What characterizes a restrictive pattern in a flow volume loop?
Small, narrow loop due to reduced lung volumes.
This pattern is observed in conditions like fibrosis, obesity, and scoliosis.
What is the FEV1/FVC ratio in obstructive disease?
Low FEV1/FVC (<70%)
What lung volumes are typically high in obstructive disease?
High RV and TLC
What is the FEV1/FVC ratio in restrictive disease?
Normal or high FEV1/FVC (>80%)
What lung volumes are typically low in restrictive disease?
Low TLC and VC
What is the diffusion capacity (DLCO) in restrictive lung disease?
Low in restrictive lung disease (fibrosis)
What is the diffusion capacity (DLCO) in asthma?
Normal/high in asthma
What is the diffusion capacity (DLCO) in emphysema?
Low in emphysema
What is the normal tidal volume (TV)?
Normal breath volume (~500mL/ 9% TLC)
What does the inspiratory reserve volume (IRV) represent?
Extra air inhaled beyond normal breath (3000ml/ 52% TLC)
What does the expiratory reserve volume (ERV) represent?
Extra air exhaled beyond normal breath (1300ml/ 22% TLC)
What is the inspiratory capacity?
Maximum amount of air that can be inhaled after a normal, quiet exhalation (TV + IRV)
What is the residual volume (RV)?
Air left in lungs after max exhalation (1000 ml/ 17% TLC)
How is vital capacity (VC) calculated?
VC = IRV + TV + ERV
What is total lung capacity (TLC)?
A sum of all lung volumes (VC + RV)
What is functional residual capacity (FRC)?
ERV + RV (air left after normal exhalation)
What is forced vital capacity?
Maximum amount of air can forcibly exhale after taking a full, deep breath
What does forced expiratory volume (FEV) measure?
Volume of air exhaled in one breath
What does forced expiratory flow (25-75%) measure?
Air flow in the middle of exhalation
What is peak expiratory flow (PEF)?
Rate of exhalation
When is a pre-op EKG indicated?
Risk factors or history of CAD, abnormal heart rates, arrhythmias or known conduction defects, males over 40 and females over 50
2014 ACC / AHA Guideline: Not indicated for low-risk surgeries
What is Wolff-Parkinson-White (WPW) Syndrome?
Symptomatic arrhythmia in the presence of an accessory pathway that links atria & ventricles bypassing the AV node
What are the EKG findings for WPW triad?
- Short PR interval (<120 ms)
- Delta wave (slurred upstroke of QRS complex)
- Wide QRS (>120 ms)
These findings are characteristic of WPW Syndrome
What symptoms are associated with WPW Syndrome?
- Palpitations
- Syncope
- Tachycardia
- Risk of sudden cardiac death if associated with atrial fibrillation
What is the treatment for stable patients with WPW?
- Vagal maneuvers
- Adenosine (if AVRT without atrial fibrillation)
What is the treatment for unstable patients with WPW?
Cardioversion if hemodynamically unstable
What is the preferred long-term treatment for WPW Syndrome?
Catheter Ablation is the preferred long-term solution
What are the alternative treatments if catheter ablation is not available for WPW?
Antiarrhythmics (e.g., procainamide)
True or False: A pre-op EKG is not indicated for low-risk surgeries.
True
Fill in the blank: WPW Syndrome links the atria and ventricles by bypassing the _______.
AV node
What is the definition of Myocardial Infarction (MI)?
Rise and/or fall of cardiac biomarkers (at least 1 value >99th % of upper limit reference range) and > 1 of the following:
* Ischemic symptoms
* New ischemic ECG changes
* Image evidence of nonviable myocardium
* Imaging showing new regional wall motion abnormalities
None
What are the EKG findings characteristic of STEMI?
ST-segment elevation ≥1 mm in two contiguous leads and new LBBB may indicate infarction
Benefits from IMMEDIATE intervention
What is the primary cause of STEMI?
Complete coronary artery occlusion
Easily identified coronary lesion
What is the management approach for STEMI?
Emergent PCI (percutaneous coronary intervention) or thrombolytics if PCI is unavailable
None
What are the EKG findings characteristic of NSTEMI?
ST depressions, T-wave inversions
More common post op by 15 X
What is the primary cause of NSTEMI?
Partial occlusion of a coronary artery (usually multiple coronary lesions)
None
What is the management approach for NSTEMI?
Anticoagulation (e.g., heparin), dual antiplatelet therapy, possible PCI with intervention within days of symptoms/after medical treatment
None
What EKG leads indicate an Anterior MI?
ST elevation in V3-V4
LAD occlusion
What EKG leads indicate an Inferior MI?
ST elevation in II, III, aVF
RCA occlusion
What EKG findings indicate a Posterior MI?
ST depressions in V1-V3 with upright T waves
PDA occlusion
What characterizes Type 1 Myocardial Infarction?
Spontaneous & related to a primary event such as plaque erosion, rupture, fissuring, or dissection; can lead to STEMI or NSTEMI
Pre-operative interventions: Plaque stabilization or statin therapy is important
What characterizes Type 2 Myocardial Infarction?
Related to imbalance between myocardial oxygen supply & demands resulting from prolonged tachycardia, coronary spasm, anemia & HTN; can lead to NSTEMI only
None
What does V1 and V2 represent in an EKG?
RV
RV stands for right ventricle.
What does V3 and V4 represent in an EKG?
Septum
The septum separates the left and right sides of the heart.
What does V5 and V6 represent in an EKG?
L side of the heart
‘L’ refers to the left side.
What does Lead I represent in an EKG?
L side of the heart
‘L’ refers to the left side.
What does Lead II represent in an EKG?
Inferior territory
This indicates the lower part of the heart.
What does Lead III represent in an EKG?
Inferior territory
This indicates the lower part of the heart.
What does aVF represent in an EKG?
Inferior territory
‘F’ stands for ‘feet,’ indicating the inferior view.
What does aVL represent in an EKG?
L side of the heart
‘L’ refers to the left side.
What does aVR represent in an EKG?
R side of the heart
‘R’ refers to the right side.
What is the recommended duration for dual antiplatelet therapy (DAPT) before elective surgery for angioplasty without stents?
2 weeks
This is beneficial before surgery.
What is the recommended duration for DAPT after angioplasty with bare-metal stents if no myocardial damage occurred?
4 weeks
This is applicable if there are no complications.
What is the recommended duration for DAPT after angioplasty with drug-eluting stents?
6 months
This is necessary to prevent clot formation.
What indicates a normal axis in EKG axis determination?
Lead I and aVF both positive
This indicates normal electrical activity in the heart.
What indicates Right Axis Deviation (RAD) in EKG axis determination?
Lead I negative, aVF positive
This can be seen in conditions like pulmonary hypertension.
What indicates Left Axis Deviation (LAD) in EKG axis determination?
Lead I positive, aVF negative
This can be seen in left ventricular hypertrophy.
What indicates extreme right axis deviation in EKG axis determination?
Lead I negative, aVF negative
This indicates significant changes in heart axis.
What is the time frame for CABG patients to undergo surgery if it is determined to be urgent?
30 days
This is the recommended waiting period.
What indicates a Normal Axis on an EKG?
Lead I & aVF both positive
Seen in healthy individuals and well-conditioned athletes
What conditions are associated with Right Axis Deviation (RAD)?
- Right Ventricular Hypertrophy (RVH)
- Pulmonary Embolism
- Lateral Myocardial Infarction
- Congenital Heart Disease
- WPW Syndrome (left-sided accessory pathway)
RVH can result from pulmonary hypertension or chronic lung disease
What conditions are associated with Left Axis Deviation (LAD)?
- Left Ventricular Hypertrophy (LVH)
- Inferior Myocardial Infarction
- Left Anterior Fascicular Block (LAFB)
- WPW Syndrome (right-sided accessory pathway)
- Hyperkalemia
LVH can be due to hypertension or aortic stenosis
What characterizes Extreme Axis Deviation?
Lead I & aVF both negative
Also referred to as ‘No Man’s Land’
What are the key features of Atrial Fibrillation?
Irregularly irregular rhythm, absent P-waves
Commonly associated with an increased risk of stroke
What is the characteristic pattern of Atrial Flutter?
Sawtooth pattern, atrial rate ~300 bpm
Often described as ‘F-waves’
What defines Supraventricular Tachycardia (SVT)?
Narrow QRS, fast regular rhythm
Typically originates above the ventricles
What are the characteristics of Ventricular Tachycardia (VT)?
Wide QRS, fast regular rhythm, potential for sudden cardiac arrest
A serious arrhythmia that can lead to decreased cardiac output
What is Torsades de Pointes?
Polymorphic VT with prolonged QT interval
Can be triggered by electrolyte imbalances or certain medications
What are common symptoms of Pulmonary Hypertension?
- Dyspnea
- Fatigue
- Syncope
Symptoms can worsen with exertion
What is the gold standard for diagnosing Pulmonary Hypertension?
Right Heart Catheterization (mean PAP >25 mmHg at rest)
Provides direct measurement of pulmonary artery pressures
What is the significance of a 6-minute walking test in Pulmonary Hypertension?
Able to walk < 600 m indicates increased disease severity and risk
Assesses exercise capacity
What are the treatment options for Primary (Idiopathic) Pulmonary Hypertension?
- Vasodilators (CCBs, PDE-5 inhibitors, endothelin receptor antagonists)
Treatments aim to improve pulmonary blood flow
What is the approach to treating Secondary Pulmonary Hypertension?
Treat underlying causes (e.g., COPD, left heart disease, thromboembolic disease)
Focuses on managing contributing conditions
What precautions should be taken regarding elective surgery in patients with Pulmonary Hypertension?
Postpone elective surgery; Have a good plan for anesthesia, avoid hypotension, keep pt on all meds
Ensures patient safety during procedures
What are the EKG changes associated with hyperkalemia?
Small P wave, Peaked T-waves, widened QRS, sine wave pattern (severe cases)
Hyperkalemia can lead to significant cardiac arrhythmias due to its effects on myocardial excitability.
What EKG changes are characteristic of hypokalemia?
Peaked P waves, Flattened T-waves, U-waves, prolonged QT interval
Hypokalemia can result in various arrhythmias and is often linked to diuretic use.
Name three drug causes of Long QT syndrome.
- TCAs
- Erythromycin
- Amiodarone
These medications can prolong the QT interval, increasing the risk of arrhythmias.
List four metabolic causes of Long QT syndrome.
- Hypothyroid
- Hypokalemia
- Hypothermia
- Hypocalcemia
Metabolic disturbances can lead to changes in cardiac repolarization.
What congenital heart defect is characterized by a left-to-right shunt and a fixed split S2?
Atrial Septal Defect (ASD)
ASD can lead to volume overload of the right heart and pulmonary circulation.
What is the hallmark murmur of Ventricular Septal Defect (VSD)?
Harsh holosystolic murmur at left lower sternal border
VSDs can lead to significant shunting and pulmonary overcirculation.
Describe the murmur associated with Patent Ductus Arteriosus (PDA).
Continuous ‘machine-like’ murmur, wide pulse pressure
PDA can cause significant left-to-right shunting, affecting systemic and pulmonary circulation.
What are the characteristic features of Tetralogy of Fallot (TOF)?
- Boot-shaped heart on CXR
- Cyanotic spells relieved by squatting
TOF is a common cyanotic congenital heart defect in children.
What clinical signs indicate Coarctation of the Aorta?
- Hypertension in upper extremities
- Weak pulses in lower extremities
Coarctation results in differential blood flow, leading to hypertension above the coarctation site.
What is the role of B-Type Natriuretic Peptide (BNP) in clinical practice?
- Differentiates cardiac vs. pulmonary causes of dyspnea
- BNP >400 pg/mL suggests heart failure
- BNP <100 pg/mL rules out heart failure
BNP levels are used to assess heart failure and guide treatment decisions.
What are the two types of heart failure based on ejection fraction?
- Systolic HF (HFrEF): EF <40%
- Diastolic HF (HFpEF): EF >50%
These classifications help guide treatment strategies and prognostic assessment.
What are the clinical signs of Left Heart Failure?
- Pulmonary congestion
- Dyspnea
- Orthopnea
Left heart failure leads to fluid accumulation in the lungs, causing respiratory symptoms.
What are the signs of Right Heart Failure?
- Peripheral edema
- JVD
- Hepatomegaly
Right heart failure results in systemic venous congestion and can be associated with left heart failure.
What is the significance of elevated BNP levels?
- Indicates increased LV wall stress
- Poor prognosis in CHF
BNP is a key marker in assessing heart failure severity and prognosis.
What treatments are commonly used for heart failure?
- ACE inhibitors/ARBs
- Beta-blockers
- Diuretics
- Aldosterone antagonists for NYHA Class II-IV
- ICD placement for EF <35%
These treatments aim to improve symptoms, reduce hospitalizations, and improve survival.
What does S1 represent in heart sounds?
Closure of mitral & tricuspid valves (beginning of systole).
What does S2 represent in heart sounds?
Closure of aortic & pulmonary valves (end of systole).
What is S3 associated with?
Volume overload, heard in heart failure (HF).
What is S4 associated with?
Pressure overload, seen in left ventricular hypertrophy (LVH).
Where is aortic stenosis best auscultated?
2nd ICS, RSB.
Where is aortic regurgitation best auscultated?
2nd ICS LSB.
Where is pulmonic stenosis best auscultated?
2nd ICS, LSB.
Where is tricuspid regurgitation best auscultated?
LLSB.
Where is mitral regurgitation, stenosis, and prolapse best auscultated?
Apex, 5th ICS, MCL.
True or False: Murmurs in the immediate newborn period always indicate congenital heart disease.
False.
What grade are murmurs usually in the immediate newborn period?
Grade 1 or 2, systolic.
What is the prevalence of innocent murmurs in children?
Very common; some studies suggest nearly all children may demonstrate a murmur.
What are the characteristics of most innocent murmurs?
- Soft, relatively short systolic ejection murmur
- Medium pitch; vibratory
- Best heard at left lower sternal or midsternal border, with no radiation to apex, base, or back.
What is important to teach parents about innocent murmurs in children?
To believe that this murmur is just a ‘noise’ and has no pathologic significance.
What is S1 also known as?
Lub/ low pitch.
What is S2 also known as?
Dub/ higher pitch.
When does S3 occur?
Immediately after S2 when AV valves open & atrial blood first pours into ventricles.
When does S4 occur?
Late diastolic sound.
What are the two types of valves in the heart?
- Atrioventricular (AV) Valves
- Semilunar (SL) Valves.
What are the AV valves?
- Mitral Valve (Left)
- Tricuspid Valve (Right).
What is the function of the AV valves?
Prevent backflow into atria during ventricular contraction.
What are common pathologies associated with AV valves?
- Mitral stenosis
- Mitral regurgitation
- Tricuspid regurgitation.
What are the SL valves?
- Aortic Valve (Left)
- Pulmonary Valve (Right).
What is the function of the SL valves?
Prevent blood backflow into ventricles after ejection.
What are common pathologies associated with SL valves?
- Aortic stenosis
- Pulmonary regurgitation.
What type of disorder is Cystic Fibrosis?
Autosomal recessive disorder affecting CFTR gene (chromosome 7).
What is the pathophysiology of Cystic Fibrosis?
Defective chloride transport → thick mucus → lung infections & pancreatic insufficiency.
Which organs are affected by Cystic Fibrosis?
- Lungs
- Sinus
- Pancreas
- Hepatobiliary
- GI
- Reproductive organs
What are common clinical features of Cystic Fibrosis?
- Chronic cough
- Recurrent lung infections (Pseudomonas)
- Nasal polyps
- Pancreatic insufficiency → steatorrhea, vitamin ADEK deficiency
- Meconium ileus in newborns
What is the sweat chloride test result indicative of Cystic Fibrosis?
> 60 mmol/L
What are some treatments for Cystic Fibrosis?
- Airway clearance (chest physiotherapy, DNase, hypertonic saline)
- Pancreatic enzyme replacement
- CFTR modulators (Ivacaftor for specific mutations)
What preoperative measures should be taken for patients with Cystic Fibrosis?
- Sputum clearance technique
- Tight glucose control
What does a carotid bruit indicate?
Turbulent blood flow, suggesting stenosis.
What is the most common cause of carotid stenosis?
Atherosclerosis; increases stroke risk.
What is the first-line diagnostic test for carotid stenosis?
Carotid Ultrasound.
What are the imaging options for detailed assessment of carotid stenosis?
- CT Angiography (CTA)
- MR Angiography (MRA)
When is Carotid Endarterectomy (CEA) or Stenting indicated?
For severe stenosis (>70%).
What technique is used to assess for carotid bruit?
Auscultate the carotid arteries.
What should be avoided when auscultating the carotid artery?
Compressing the artery, which can create an artificial bruit.
What is the Revised Cardiac Risk Index (RCRI) used for?
Predicts perioperative risk based on several factors.
What are major risk factors according to ACC/AHA Guidelines?
- History of CAD or stroke
- Diabetes mellitus
- Chronic kidney disease
- Smoking
- Hypertension
- Hyperlipidemia
What factors are included in the RCRI for assessing risk?
- Ischemic heart disease
- CHF
- Stroke
- Insulin-dependent diabetes
- Renal failure
What MET level indicates low MACE during the majority of surgeries?
MET’s >4.
Fill in the blank: ‘Can you climb two flights of stairs without stopping and without chest pain or shortness of breath’? = _______
> 4
Fill in the blank: ‘Can you walk two to four blocks on a level surface without having chest pain or shortness of breath’? = _______
> 4
What are the EKG findings for Right Bundle Branch Block (RBBB)?
Wide QRS (>120 ms), RSR’ (rabbit ears) in V1-V2, deep S wave in leads I and V6
RBBB is 3 times more common than LBBB
List common causes of Right Bundle Branch Block (RBBB).
- Pulmonary embolism
- RVH
- Congenital heart disease
RBBB can be an isolated anomaly without any underlying disease
What are the EKG findings for Left Bundle Branch Block (LBBB)?
Wide QRS (>120 ms), broad notched R wave in V5-V6, deep S wave in V1, absent Q wave in lateral leads
LBBB is more likely to be related to underlying heart disease
List common causes of Left Bundle Branch Block (LBBB).
- Hypertension
- CAD
- Dilated cardiomyopathy
LBBB may lead to systolic/diastolic dysfunction and heart failure
What are the indications for heart transplants?
- End-stage heart failure (NYHA Class IV, EF <20%)
- Severe congenital heart disease
- Cardiomyopathies unresponsive to medical therapy
Lifelong immunosuppression is required post-transplant
What lifelong medications are required after a heart transplant?
- Tacrolimus
- Mycophenolate
- Steroids
Risk of rejection necessitates biopsy surveillance
What are the preoperative considerations with Automatic Implantable Cardioverter Defibrillator (AICD)?
- Interrogate device before surgery
- Monopolar cautery can impact defibrillator
- Disable shocks during electrocautery procedures
- Ensure magnet availability to suspend therapy
Cutting above the umbilicus can have a significant impact
What should be monitored postoperatively for AICD?
- Re-enable device and confirm functionality
- Monitor for pacemaker dependency
Magnet should stay in place if needed
What is the position to assess Jugular Venous Distension (JVD)?
Position a person supine at a 30- to 45-degree angle
This position allows for the best visibility of pulsations
What does the ‘a wave’ in the components of the jugular pulse represent?
Atrial contraction
Other components include c wave, x descent, v wave, and y descent
What is considered normal blood pressure?
120/80
Pre-HTN is 120-139/80-89
Define Stage 1 Hypertension.
140-159/90-99
Stage 2 Hypertension is >160/100
List secondary causes of hypertension.
- CKD
- Coarctation of the aorta
- Endocrine disease
- Primary aldosteronism
- Thyroid or parathyroid disease
- Pheochromocytoma
- Medications
- OSA
Hypertension can lead to various complications including eye damage and stroke
True or False: Aggressively treating hypertension just prior to surgery can lead to severe intraoperative hypotension.
True
This may result in organ hypoperfusion and ischemia
