Test weeks 4-8 Flashcards
Heart Sounds
S1 - mitral and tricuspid valves
S2 - systole ends, pulmonic and aortic valves close
Normal Lub Dub
Heart Sounds
S3 - suggest CHF
S4 - cardiac abnormality MI or cardiomegaly
Both hard to hear
Murmur
Abnormal heart sound caused by turbulent flow
- valve defects or congenital abnormalities
- blood pushed through abnormal opening, like a shunt
ECG or EKG
electrocardiogram
indirect measurement of the hearts electrical activity
12 lead is 12 different angles of the heart
What does the EKG show?
blocks, ST and T changes, MI vs injury, disrhythmias, change in medication and electrolytes
Indications for EKG
Signs/symptoms of CHF, Angina, Acute MI
SA Node
Main pacer of the heart 60 - 99 bpm
P with every QRS means SA is firing
AV Node
secondary pacer if SA fails
PR is measured beginning of P to beginning of Q
40 - 60 bpm
Internodal and interatrial pathways
AV Node
Bundle of HIS
Perkinje Fibers
1st - Depolarization
Contraction
P and QRS wave
2nd - Repolarization
Relaxation
returning to polarized position
T wave
Automaticity
Cardiac cells depolarize without stimulation of nerve
Conduction system
responsible for controlling rate at which the heart contracts
ST segment
Beginning of S to beginning of T
*when not enough O2, ST seg will be depressed
Normal Sinus Rhythm
Regular 60 - 100 bpm QRS Normal Pwave visible before each QRS PR interval normal
Sinus arrhythmia
60 - 100 bpm irregular P wave uniform and upright PR interval 0.12 - 0.20 sec QRS < 0.10 sec
Super Ventricular Tachycardia
Rate > 150 bpm Narrow QRS P & T close together "Bear Down" vagal response (amiodarone)
Atrial Flutter
Regular Rate around 110 bpm QRS normal P wave replaced w/multiple F (flutter) waves ratio 2:1 (2F:1QRS) P wave 300 bpm PR interval not measurable sometimes sawtooth
1st Degree AV block
Regular Rate normal QRS normal P wave 1:1, normal rate PR interval prolonged (>5 small squares)
2nd Degree Block Type 1 (Wenkebach)
Regularly irregular Rate normal or slow QRS normal P wave 1:1, normal rate, faster than QRS PR interval progressive lengthening until QRS is dropped *decreased CO
2nd Degree Block Type 2
Regular
Rate normal or slow
QRS prolonged
P wave 2:1 or 3:1, normal rate, faster than QRS
PR interval normal or prolonged but constant
*ischemia
3rd Degree Block (Complete)
Regular Rate slow QRS prolonged P wave unrelated, normal rate, faster than QRS PR interval variation
Complete AV block
no atrial impulses pass through the atrioventricular node and the ventricles generate their own rhythm
Premature Ventricular Contractions
Regular Rate normal QRS normal P wave 1:1, normal rate, same as QRS PR interval normal *Ventricle fires early, one up, one down
Ventricular Tachycardia
Regular 180 - 190 bpm QRS prolonged P wave not seen *decreased CO, BP, cardiovert
Ventricular Fibrillation
Irregular 300+ bpm QRS not recognizable Pwave not seen DEFIBRILLATE! heart is quivering
Asystole
Rhythm flat Rate 0 QRS none P wave none *carry out cpr, check leads!
Bundle Branch Block
an impulse is blocked as it travels through the bundle branches
Right Bundle Branch Block
branch defective so that the electrical impulse cannot travel through it to the right ventricle, activation reaches right ventricle by proceeding from the left ventricle
Travels through septal and right ventricular muscle mass
Left Bundle Branch Block
Activation of left ventricle is delayed, which results in the left ventricle contracting later than the right ventricle
LBBB is seen in lead V5 and V6
Junctional
AVN firing faster than SN resulting in a regular narrow complex rhythm
Maybe demonstrate retrograde P waves, or not present
rates 40 - 60 bpm
LOOKS NORMAL, OR PWAVE MISSING OR INVERTED
Symptoms of Junctional
Palpitations Fatigue Light Headed Dyspnea Poor exercise tolerance
Holter Monitor
Detects arrythmias not seen on resting EKG
Take home EKG
outpt procedure
Provides continuous electrical recording 24-48 hrs
Activity, Sleep, Rest
Combines EKG during ADL
Echocardiogram
Non-invasive, uses sound waves Observes heart structures Function of the heart ventricular and valve Blood flow, direction, amount
Why Echo?
Pericardial effusion/pericarditits
Valvular heart disease
Cardiac tumors/blood clots
Septal wall defects - VSD, ASD, congenital
Types of Echo tests
M-Mode echocardiogram
2D
Color doppler (red and blue indicate flow direction)
Trans-esophageal (TEE) (better visualization, no bones or lungs, visualize back of the heart)
Cardiopulmonary Exercise Test (CPET)
Graded or steady exercise test with EKG and pulmonary gas exchange assessment
Mouthpiece or face mask collects exhaled gas
Pulmonary parameters measured during CPET
Minute vent
SpO2, ABG, PETCO2, Vd/Vt
CO2 production, O2 consumption
FVC and FEV1 measurements pre and post exercise
Cardiac parameters measured during CPET
HR and rhythm, BP
Indications for CPET
Explain dyspnea and limiting activity Rule out cardiac disease w/lung disease Establish occupational disability Rule out exercise induced hypoxemia Obtain baseline exercise level
Other indications for CPET
Pre-evaluation assessment
- Pulmonary rehab
- Cardio - thoracic surgery
- Fitness program
- Endurance training
Relative contraindications for CPET
Physical limitations -Arthritis, osteoarthritis of lower extremities -Recent surgery of lower extremities -Hip, knee, joint pain Cerebral vascular disease Syncope Pulmonary Related -FEV1 < 30% predicted -PaO2 < 40 mmHg on RA -PaCO2 > 70 mmHg -Recent pulmonary embolus -Severe pulmonary hypertension
Absolute Contraindications for CPET
Cardiac Related -recent MI -Unstable chest pain suspicious of cardiac pain Uncontrolled hypertension -SBP > 200 mmHg, DPB > 110 mmHg COPD exacerbation Rapid atrial or vent arrhythmias Recent systemic embolus Severe CorPulmonale
Personnel for CPET
2 experienced clinicians and MD
- BLS/ACLS certified
- RT
- RN
- Exercise physiologist
Testing parameters for CPET Minute Ventilation (Ve)
Ve increases directly with increasing workload and increase in CO2 production
-Predicted Ve max (MVV) = FEV1 x 35
Measured by electronic flow transducer
At rest 6 - 12 lpm
-during exercise >/= 100 lpm (avg sedentary)
->/= 200 lpm conditioned athlete
Testing parameters for CPET Oxygen Consumption (Vo2)
Volume consumed or used during exercise
Single best measure of work being performed
-Normal resting Vo2 is 3.5 ml/min
-To measure Vo2, exhaled gas is accumulated
Vo2 = FeO2-FeCO2/FiO2
Metabolic Equivalents (METS)
Amount of oxygen being consumed to perform a particular activity
Resting metabolism = 1 MET (Vo2 3.5 ml/kg)
Healthy sedentary should be able to work up to 7 METS
VO2 Max
Maximum Oxygen Consumption
Highest amount of oxygen extracted by the body from the volume of air breathed into the lungs
-Level at which symptoms become overwhelming
Predicted VO2 max
Based on age, height, gender -Young adults 80 ml/kg -Seniors 30 ml/kg -Presence of disease < 30 ml/kg Vo2 max (act) / Vo2 max (pred) = % pred Normal is >/= 80% predicted
VcO2
Carbon Dioxide Production
Reflection of metabolism during activity
- measured via exhaled gas sampling
- VcO2 = (FeCO2 - 0.0003) x Ve
- VcO2 rises directly with workload
- Ve rises directly with VcO2 and lactic acid production
Normal exercise physiology
Exercise increases metabolic need of the tissues for O2 (aerobic metabolism)
- both the lungs and cardiac system must be able to meet these demands
- Pulm system increase oxygen availability by increasing Ve (IRV) and Zone 1 and 2 perfusion
- Cardiac system increases oxygen delivery by
- -increasing HR and SV = Increasing CO
Normal exercise physiology (cont’d)
As workload is steadily increased, O2 consumption continues to rise until Vo2 max is reached
- VcO2 continues to rise until the body cannot perform work aerobically
- Body then switches to anaerobic metabolism (anaerobic threshold - AT)
Anaerobic Threshold (AT)
Anaerobic metabolism
- Producing work without oxygen
- Producing more CO2 than consuming O2
- Occurs at about 60 - 70% of Vo2 and Ve Max
- can only maintain continued exercise for a short duration (exhaustion)
- Occurs where Ve rises sharply in contrast to VO2 consumption
- Point where Ve breaks away from the linear relationship with Vo2
Respiratory Exchange Ratio (RER)
RER = VcO2/VO2
- Normal aerobic RER will be 0.7 - 0.9
- RER increases from 0.7 (at rest) with increasing workload as CO2 production increases
Anaerobic metabolism (AT) the RER will be > 1.0 due to CO2 production - Good indicator of maximal effort by patient during testing
Treadmill Protocols
- Use of standard walking treadmill (more natural)
- Work (METS) are increased by
- Increasing treadmill speed and grade
- Graded levels are usually spaced 2-3 minutes
- Work levels are increased until
- Pt cannot tolerate
- Abnormal response occurs
- VO2 Max or HR Max achieved
Stationary Cycle Ergometry
Increase workloads expressed as “watts”
- Wheel belt tension increased every 30 seconds to 4 minutes making pedaling more difficult
In most people, cycling does not produce a high VO2 as the treadmill
- set supports pt’s weight
- Pts with difficulty ambulating, obese pt
Advantages
Treadmill - natural form of exercise, Higher Vo2 Max
Cycle - Safer than treadmill, easier to monitor, easier to obtain ABG
Disadvantages
Treadmill - Risk of accident, pt. anxiety, motion artifact, ABG difficulty
Cycle - Legs fatigue more quickly, Lower VO2 Max
Testing procedure
Baseline Data - 3 minute resting data Active exercise data - VO2, VCO2, Ve, HR, RR, SpO2, RER - Parameters taken at 1 minute intervals during staging Cool down and Recovery Care - ABG, spirometry, B2 if needed
Indications for test termination
Patient exhaustion, fatigue, dyspnea, pain
Vo2 Max or AT has been reached
Heart Rate and rhythm changes
- Reaches predicted HRmax (220 - age)
- ST segment decreases by 2 mm
- Chest pain
- Blood pressure changes
- systolic drops by 20 mmHg or no increase
- systolic > 250; diastolic > 120 mmHg
Normal Response to Test
Predicted VE Max is reached
- Ve will increase at onset of anaerobic metabolism due to the increased CO2 production
Cardiac
- Increase systolic blood pressure
- Minimal to no increase in diastolic pressure
- HR increases with Vo2 until max HR is reached
Normal Response to Test (con’t)
Increase in - SpO2 slightly - PaO2 - Lactic Acid - BP & HR - RR & Ve - Vo2 & VCO2 Decrease in - pH - Vd/Vt - PaCO2
Normal Response to Test (cont’d)
- Exercising causes HR to increase linearly
- HR will continue to increase linearly until max predicted HR is reached
Sedentary Response
HR will increase linearly with VO2, however it is greater at each level of VO2 (outside the normal range)
BP and SpO2 will have a normal response
Pulmonary Interpretation
Pulmonary Limited Exercise
- Vent limited
- did not reach VO2 Max due to breathing impairment
- Did not achieve anaerobic threshold
- Ve max is greater than 70% of their MVV
- Increased Vd/Vt
- PaO2 will decrease
- PA-aO2 will increase
- EKG normal
- HR max is less than 85% predicted HR at completion
Pulmonary Limited Exercise Prescription
Pt. should spend 5 minutes in warm up activities
Pt. should exercise 20 min at target HR
- target = (Max HR - Resting HR) .70 + Resting
Pt. should spend 5 minutes in cool down activities
Benefits of Exercise Program
COPD pt will have increased
- exercise tolerance
- overall strength
- oxygen use efficiency
- quality of life
Decreased dyspnea
Cardiac Interpretation
Cardiac Disease Limited
- Circulation (CO) Limited
- HR max achieved sooner than Ve max or VO2 Max predicted
- Ve max is less than 50% of their MVV
- EKG shows arrhythmia, ST changes, or both
- Systolic pressure drops
- Diastolic pressure increases
Deconditioned Interpretation
Deconditioned subjects
- have same response as CV except the EKG is normal
- HR max reached before Vo2 max
- Dyspnea limitation
- Leg cramping
What does Neurological assessment evaluate?
- Mental Status
- Cranial nerve function
- Motor system
- Coordination
- Sensory pattern
- Reflexes
Meaningful neurologic assessment requires adequate stimulation
Nervous System
- Afferent (periphery to CNS)
- Efferent (CNS to rest of body)
- Review brain
- Brainstem
BIS
band on forehead monitors sedation LOC > 60 not sedated enough Brain waves measure electrical activity < 20 - 10 too much sedation
Brainstem
Midbrain
Locus coeruleus
Pons
Medulla
Hypothalamus
Temperature
LOC
Level of consciousness
Lethargic
sleepy, but can awake and answer questions
Obtunded
needs more stimulation
can do simple commands
Stupor
constant pain stimulation to answer
no commands
Persistent vegetative state (coma)
unresponsive to stimulation
Glasgow Coma Scale
Assesses the LOC after head injury
tests verbal, motor, eye opening, etc.
12 - 15 good, non-icu
<9 Coma
Delirium - longer stay in icu, 60 - 80% of MV pts.
