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Sim Lab 2 > Vascular and Pericardial Dx > Flashcards

Vascular and Pericardial Dx Flashcards

1
Q

PMI

A

Perioperative Myocardial Infarction

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2
Q

When does myocardial ischemia occur?

A

O2 demand > O2 Supply

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3
Q

Which leads do we watch for ischemia?

A

V2 and V5

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4
Q

ST changes in STEMI

A

ST elevation possible T wave inversion

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5
Q

ST chnages in NSTEMI

A

ST depression or T wave inversion

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6
Q

Cardiac Risk for Non-Cardiac Surgeries: High Risk

TAMP

A
  • Thoracotomy
  • AAA
  • Major Abdominal Procedure
  • Peripheral Vascular Procedure
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7
Q

Cardiac Risk for Non-Cardiac Surgeries: Ischemia Heart DX

CHHUP

A
  • Current Angina
  • Hx of MI
  • Hx of positive exercise test
  • Use of Nitrates
  • Presence of Q waves

Q wave: a small negative wave immediately before the large QRS complex

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8
Q

Cardiac Risk for Non-Cardiac Surgeries: CHF

HHH-PC

A
  • Hx of CHF
  • Hx of Pulmonary Edema
  • Hx of paroxysmal noctural dyspnea
  • Physcial with rales or S3 gallop
  • Chest Xray shopwing pulmonaly vascular redistribution
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9
Q

Cardiac Risk for Non-Cardiac Surgeries: Cerebrovascular Dx

2

A
  1. Hx of CVA
  2. Hx of TIA
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10
Q

Cardiac Risk for Non-Cardiac Surgeries: Renal Function

A

Pre-op creatine > 2mg/dL

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11
Q

Cardiac Risk for Non-Cardiac Surgeries: DM

A

Insulin dependance

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12
Q

Why do patinets with DM have silent MI’s?

A

Nerve damage prevents them from feeling pain from MI

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13
Q

PMI management

A
  • Prevent myocardial ischemia
  • Avoid hyperventilation
  • HR and BP within 20% of baseline
  • Avoid sympathetic responses
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14
Q

PMI Intra-Op Events: Decreased O2 supply

OH-DATCHA

A
  • Oxyhemoglobin shift: Left
  • Hypotension
  • Decreased coronary blood flow
  • Arterial Hypoxemia
  • Tachycardia
  • Coronary Artery Spasm
  • Hypocapnia
  • Anemia
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15
Q

PMI Intra-Op Events: Increased O2 demands

SIIITH

A
  • Sympathetic stimulation
  • Increased Inotropy
  • Increased Preload
  • Increased Afterload
  • Tachycardia
  • Hypertension
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16
Q

PMI IntraOp treatment

1mm change in ST segment

A
  • Nitro to reduce afterload
  • Esmolol to reduce HR
  • Inotropes to increase BP
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17
Q

PMI: Avoid in PostOp

SPS-HHH

A
  • Shivering
  • Pain
  • Sepsis
  • Hypoxemia
  • Hypercarbia
  • Hemorrhage
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18
Q

AAA’s are associated with what?

A
  • Marfans
  • Ehler-Danlos
  • Bicuspid Aoritc Valve
  • Family Hx
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19
Q

AAA’s not operated on until what size?

A

Larger than 5cm

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20
Q

Aortic Dissections are associated with what?

PTW-HABIT

A
  • Pregnancy
  • Tetrology of Fallot (TOF)
  • Weight Lifting
  • HTN
  • Atherosclerosis
  • Bicuspid Aortic Valve
  • IABP/CABG/Aortic Surgery
  • Trauma (from ligamentum arteriosum)
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21
Q

AAA Rupture Triad

A
  1. Severe Back Pain
  2. Pulsatile Abdominal Mass
  3. Hypotension
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22
Q

How are AAA patients stable until surgery?

A

The abdominal blood tamponades the rupture, once incision is made massive blood loss will happen

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23
Q

Aortic dissection classifications

2 kinds

A
  • DeBakey
  • Standford
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24
Q

DeBakey Type I

A

involves ascending and descending aorta (= Stanford A)

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25
Q

DeBakey Type II

A

involves ascending aorta only (= Stanford A)

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26
Q

Debakey Type III

A

involves descending aorta only, commencing after the origin of the left subclavian artery (= Stanford B)

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27
Q

Stanford Type A

A

type A involves any part of the aorta proximal to the origin of the left subclavian artery (A affects ascending aorta)

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28
Q

Stanford Type B

A

type B arises distal to the left subclavian artery origin

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29
Q

Medical Management of Ascending Aorta

A

Surgical Intervention

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30
Q

Medical Management of Aortic Arch

A

Surgical intervention

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31
Q

Medical Management of Aortic Arch involving the Innominate

AKA Brachiocephalic artery

A
  • Bypass required
  • Profound hypertension
  • ± Circulatory Arrest
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32
Q

Medical Management of Descending Aorta

A

Surgical intervention only if about to rupture or growing too fast. Otherwise just medicically managed

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33
Q

What can aortic cross clamping do to the spine?

A

Anterior Spinal Artery Syndrome

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34
Q

How does Anterior Spinal Artery Syndrome manifest?

A
  • Flaccid Paralysis
  • Motor Dysfunction
    * Lower Extremities
    * Bowel
    * Bladder
  • Acute back pain at the level of clamping/injury
  • Autonomic dysfunction
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35
Q

How do we reduce the risk of Anterior Spinal Artery Syndrome?

A
  • Cross clamp less than 30 mins
  • Possible bypass if longer than 30 mins to increase blood flow
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36
Q

What happens to SVR distal and proximal to the clamp on the aorta?

A

Distal: SVR decrease
Proximal: SVR increase

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37
Q

Change in HR after aortic clamp?

A

None

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38
Q

What is the global venous response to te aortic clamping?

A

Vasoconstriction

39
Q

What pressures increase after aortic clamping?

A
  • CVP
  • PAP
  • PAWP
40
Q

We need to measure pressures above and below clamp, how do we do that?

A

two art lines or NIBP cuffs

41
Q

What MAP do we need to see above and below the clamp?

A

Above: 100mmHg
Below: 50mmHg

42
Q

What three things have a habit of not getting perfused after clamping?

A
  1. Bowel
  2. Kidneys
  3. Splanchnic organs
43
Q

Evoked Potentials and Aortic cross clamping

Catch 22

A

Motor: Can’t use, pt paralyzed

Sensory: only monitor dorsal aspect, we need ventral measurements

44
Q

So what do we do?

A
  • We can only insure we use proper perfusion pressures
  • Lumbar Puncture drain (<10cm H2O of CSF)
  • Iced Epidural Injection
45
Q

Aortic Unclamping -vs- Clamping

A
  • Un-clamp
  • Peripheral blood pooling
  • Central hypovolemia
  • Decreased venous return
  • Hypotension

Hypoxia mediated vasodilaiton and metabolite washout will ensue

46
Q

Aortic Unclamping -vs- Clamping

A
  • Clamping
  • Vasoconstriction
  • Increased venous return
  • Increased lung and intracrainia blood volume
  • Hypertension
47
Q

Slow or fast release of the clamp is advised?

A

Slow

48
Q

What does Mannitol do for the kidneys?

A
  • Increase renal blood flow
  • Increase GFR
49
Q

Chilled LR, mannitol, and methylprednisilone is what?

A

Renal artery injection

50
Q

Do we put a lower bair hugger on these patients?

A

No they will get a burn, body can not regulate heat during clamping

51
Q

Endovascular aortic repair: Where is it more difficult?

A

Thoracic at the arch

52
Q

Endovascular aortic repair: Management and precautions

A
  • Spinal cord ischemia still possible
  • Monitor BP with art line
  • Monitor urine output
  • Possible lumbar puncture
  • Be ready to open
  • maintain volume and BP
53
Q

Know Circle of Wilis anatomy

A
  • Ant, Middle, Post arteries
  • Internal Carotid
  • Vertebral arteries form Basilar Artery
54
Q

Two types of strokes?

A
  • Ischemic
  • Hemorrhagic
55
Q

Carotid Stenosis: Diagnosis

A
  • Auscultation
  • Angiography
  • CT
  • MRI
  • Doppler
56
Q

What are we listening for with the bell of the stethescope on the caroid?

A

Carotid bruit

“brewie”: sound made by stenotic vessel

57
Q

When is surgery indicated for a stenotic carotid?

A

70-99% blockage, then pt gets a Carotid Endarterectomy

58
Q

CEA

A

Carotid endarterectomy

59
Q

CEA patients also have a high chance of what other diesases?

A
  • CAD
  • HTN
60
Q

CEA: Regional Blocks

A
  • This gives us a real time assesment of stroke as pt is awake and responsive
  • We do a cervical plexus block and sedation
  • Rarely used
61
Q

CEA: General Anesthesia

A

We need to maintaine
* HR
* BP
* Pain
* Stress

62
Q

CEA: Why do we get wild swings in hemodynamics?

A

Carotis sinus body: chemoreceptors and baroreceptors

manipulations give off signals to alter BP

63
Q

CEA: Hemodynamic swing management

A
  • Vasodilators
  • Phyenylephrine / ephedrine
  • Surgeon can inject local into the carotid body to help smooth out patient
64
Q

CEA: perfusion / collateral flow concerns

A
  • may or may not shunt to give adequate perfusion
  • we need to monitor blood flow if we suspect cerebral ischemia
65
Q

CEA: How do we monitor for cerebral ischemia?

A
  • EEG
  • SEP
  • Doppler
  • Cerebral Oximetry
  • Stump Pressure
66
Q

CEA: What is stump pressure?

A

non-compliant tubing attahced to a cannula is inserted into the cephelad aspect of the clamped carotid in order to determine if aquetuate collateral flow is present

67
Q

CEA: What is cerebral oximitry?

A

measures tissue oxygen saturation

68
Q

In the cerebral cortex what are the hemoglobin distrobution percentages?

A
  • Venous: 70%
  • Arterial: 30%
69
Q

CEA: Post OP Complications

Cardiac

A
  • HTN or Hypotension due to sinus body manipulations
  • MI
70
Q

CEA: Post OP Complications

Airway

A
  • Tissue Edema
  • Hematoma in neck
71
Q

CEA: Post OP Complications

Neurologic

A
  • Stroke
  • thrombosis formation
  • Hypoglossal dysfunction (motor tongue)
  • RLN dysfunction (one sided vocal chord paralysis, hoarsness)
  • Superior laryngeal dusfunciton (phonation chnages)
72
Q

Which cranial nerve is the Hypoglossal?

A

12 (XII)

73
Q

What is the pericardial sac

A

fibrous sac that produces fluid to help lubricate the movement of the heart

Anatomy
* Fibrous
* Serous
* Visceral
* Parietal

74
Q

How much fluid is usually in the paericardial sac?

A

10-50mL

75
Q

Small effusion streches what in the fibrous layer?

A

elastin

76
Q

Large effusion streches what in the fibrous layer?

A

collagen

77
Q

Drainage of pericardial sac, what lymnph nodes

BTM

A

Bronchial
Trachial
Mediastinal

78
Q

Pericarditis

Most common pericardial disorder

A
  • Friction rub
  • Recurrent
  • Mimincs MI but does not improve with Nitro
  • Longer duration with slower onset
79
Q

Pericardial effusion common causes

MIC-DRST

excess fluid in the pericardial sac

A
  • MI
  • Infection
  • Cancer
  • Drugs
  • Radiaiton
  • Systemic disease
  • Trauma

MIC are the big three

80
Q

Cardiac Tamponade

A

Fluid in the pericardial sac that causes severe cardiac compression

81
Q

How do we diagnose tamponade

A
  • Chest X ray
  • CT
  • TTE/TEE
82
Q

Signs and symptoms of Cardiac Tamponade

AP-HIDE

A
  • Activation of sympathetic system
  • Pulsus Paradoxus
  • Hypotension
  • Increased ICP
  • Decreased voltage on EKG
  • Equalization of cardiac filling pressures
83
Q

What adjacent structures can this tamponade compress?

A
  • Esophagus
  • Trachea
  • Lungs
84
Q

What is Kassmaul’s sign

A

Jugular vein distentsion on inspiration

85
Q

What is Beck’s Triad

A
  • Hypotension
  • Jugular vein distention / increased pressure
  • Muffled heart sounds
86
Q

What is pulsus paradoxus

A

ventricular interdependence seen on EKG
decrease of >10mmHg in systolic pressure during spontaneous respiration

87
Q

Cardiac Tamponade: EKG

A
  • Lower QRS volatge (smaller QRS complex)
  • Can see alternans
88
Q

Cardiac Tamponade: Echo

A
  • Small <10mm
  • Medium 10-20mm
    *Large >20mm
  • Chamber compression
  • Swinging motion
  • Collapse on inspiration
89
Q

What two treats are available for cardiac tamponade

A
  1. pericardiocentesis
  2. pericardial window
90
Q

What induction drug do we use for tamponade?

A

Ketamine

1-2.5mg/kg

91
Q

Tamponade mangement

A

Preload dependant
Maintain CO
Maintain Inotopy
Maintain Chronotropy
Maintain SV

92
Q

Tamponade: avoid what

A
  • Myocardial depression
  • Hypovolemia
  • Hypervolemia
  • Arterial Vasodilation
  • Bradycardia
  • PPV
93
Q

Watch out for what two things after post decompression cardiac tamponade?

A

Hypertension induced
* Aortic dissection
* Aortic Aneurysm

Sim Lab 2 (6 decks)

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