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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
DeBakey Type II
involves ascending aorta only (= Stanford A)
26
Debakey Type III
involves descending aorta only, commencing after the origin of the left subclavian artery (= Stanford B)
27
Stanford Type A
type A involves any part of the aorta proximal to the origin of the left subclavian artery (**A** **a**ffects **a**scending **a**orta)
28
Stanford Type B
type B arises distal to the left subclavian artery origin
29
Medical Management of Ascending Aorta
Surgical Intervention
30
Medical Management of Aortic Arch
Surgical intervention
31
Medical Management of Aortic Arch involving the Innominate ## Footnote AKA Brachiocephalic artery
* Bypass required * Profound hypertension * ± Circulatory Arrest
32
Medical Management of Descending Aorta
Surgical intervention only if about to rupture or growing too fast. Otherwise just medicically managed
33
What can aortic cross clamping do to the spine?
Anterior Spinal Artery Syndrome
34
How does Anterior Spinal Artery Syndrome manifest?
* Flaccid Paralysis * Motor Dysfunction * Lower Extremities * Bowel * Bladder * Acute back pain at the level of clamping/injury * Autonomic dysfunction
35
How do we reduce the risk of Anterior Spinal Artery Syndrome?
* Cross clamp less than 30 mins * Possible bypass if longer than 30 mins to increase blood flow
36
What happens to SVR distal and proximal to the clamp on the aorta?
Distal: SVR decrease Proximal: SVR increase
37
Change in HR after aortic clamp?
None
38
What is the global venous response to te aortic clamping?
Vasoconstriction
39
What pressures increase after aortic clamping?
* CVP * PAP * PAWP
40
We need to measure pressures above and below clamp, how do we do that?
two art lines or NIBP cuffs
41
What MAP do we need to see above and below the clamp?
Above: 100mmHg Below: 50mmHg
42
What three things have a habit of not getting perfused after clamping?
1. Bowel 2. Kidneys 3. Splanchnic organs
43
Evoked Potentials and Aortic cross clamping ## Footnote Catch 22
Motor: Can't use, pt paralyzed Sensory: only monitor dorsal aspect, we need ventral measurements
44
So what do we do?
* We can only insure we use proper perfusion pressures * Lumbar Puncture drain (<10cm H2O of CSF) * Iced Epidural Injection
45
Aortic **Unclamping** -vs- Clamping
* Un-clamp * Peripheral blood pooling * Central hypovolemia * Decreased venous return * Hypotension ## Footnote Hypoxia mediated vasodilaiton and metabolite washout will ensue
46
Aortic Unclamping -vs- **Clamping**
* Clamping * Vasoconstriction * Increased venous return * Increased lung and intracrainia blood volume * Hypertension
47
Slow or fast release of the clamp is advised?
Slow
48
What does Mannitol do for the kidneys?
* Increase renal blood flow * Increase GFR
49
Chilled LR, mannitol, and methylprednisilone is what?
Renal artery injection
50
Do we put a lower bair hugger on these patients?
No they will get a burn, body can not regulate heat during clamping
51
Endovascular aortic repair: Where is it more difficult?
Thoracic at the arch
52
Endovascular aortic repair: Management and precautions
* 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
Know Circle of Wilis anatomy
* Ant, Middle, Post arteries * Internal Carotid * Vertebral arteries form Basilar Artery
54
Two types of strokes?
* Ischemic * Hemorrhagic
55
Carotid Stenosis: Diagnosis
* Auscultation * Angiography * CT * MRI * Doppler
56
What are we listening for with the bell of the stethescope on the caroid?
Carotid bruit ## Footnote "brewie": sound made by stenotic vessel
57
When is surgery indicated for a stenotic carotid?
70-99% blockage, then pt gets a Carotid Endarterectomy
58
CEA
Carotid endarterectomy
59
CEA patients also have a high chance of what other diesases?
* CAD * HTN
60
CEA: Regional Blocks
* 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
CEA: General Anesthesia
We need to maintaine * HR * BP * Pain * Stress
62
CEA: Why do we get wild swings in hemodynamics?
Carotis sinus body: chemoreceptors and baroreceptors manipulations give off signals to alter BP
63
CEA: Hemodynamic swing management
* Vasodilators * Phyenylephrine / ephedrine * Surgeon can inject local into the carotid body to help smooth out patient
64
CEA: perfusion / collateral flow concerns
* may or may not shunt to give adequate perfusion * we need to monitor blood flow if we suspect cerebral ischemia
65
CEA: How do we monitor for cerebral ischemia?
* EEG * SEP * Doppler * Cerebral Oximetry * Stump Pressure
66
CEA: What is stump pressure?
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
CEA: What is cerebral oximitry?
measures tissue oxygen saturation
68
In the cerebral cortex what are the hemoglobin distrobution percentages?
* Venous: 70% * Arterial: 30%
69
CEA: Post OP Complications Cardiac
* HTN or Hypotension due to sinus body manipulations * MI
70
CEA: Post OP Complications Airway
* Tissue Edema * Hematoma in neck
71
CEA: Post OP Complications Neurologic
* Stroke * thrombosis formation * Hypoglossal dysfunction (motor tongue) * RLN dysfunction (one sided vocal chord paralysis, hoarsness) * Superior laryngeal dusfunciton (phonation chnages)
72
Which cranial nerve is the Hypoglossal?
12 (XII)
73
What is the pericardial sac
fibrous sac that produces fluid to help lubricate the movement of the heart Anatomy * Fibrous * Serous * Visceral * Parietal
74
How much fluid is usually in the paericardial sac?
10-50mL
75
Small effusion streches what in the fibrous layer?
elastin
76
Large effusion streches what in the fibrous layer?
collagen
77
Drainage of pericardial sac, what lymnph nodes ## Footnote BTM
Bronchial Trachial Mediastinal
78
Pericarditis ## Footnote Most common pericardial disorder
* Friction rub * Recurrent * Mimincs MI but does not improve with Nitro * Longer duration with slower onset
79
Pericardial effusion common causes | MIC-DRST ## Footnote excess fluid in the pericardial sac
* **MI** * **Infection** * **Cancer** * Drugs * Radiaiton * Systemic disease * Trauma ## Footnote MIC are the big three
80
Cardiac Tamponade
Fluid in the pericardial sac that causes severe cardiac compression
81
How do we diagnose tamponade
* Chest X ray * CT * TTE/TEE
82
Signs and symptoms of Cardiac Tamponade ## Footnote AP-HIDE
* Activation of sympathetic system * Pulsus Paradoxus * Hypotension * Increased ICP * Decreased voltage on EKG * Equalization of cardiac filling pressures
83
What adjacent structures can this tamponade compress?
* Esophagus * Trachea * Lungs
84
What is Kassmaul's sign
Jugular vein distentsion on inspiration
85
What is Beck's Triad
* Hypotension * Jugular vein distention / increased pressure * Muffled heart sounds
86
What is pulsus paradoxus
ventricular interdependence seen on EKG decrease of >10mmHg in systolic pressure during spontaneous respiration
87
Cardiac Tamponade: EKG
* Lower QRS volatge (smaller QRS complex) * Can see alternans
88
Cardiac Tamponade: Echo
* Small <10mm * Medium 10-20mm *Large >20mm * Chamber compression * Swinging motion * Collapse on inspiration
89
What two treats are available for cardiac tamponade
1. pericardiocentesis 2. pericardial window
90
What induction drug do we use for tamponade?
Ketamine ## Footnote 1-2.5mg/kg
91
Tamponade mangement
Preload dependant Maintain CO Maintain Inotopy Maintain Chronotropy Maintain SV
92
Tamponade: avoid what
* Myocardial depression * Hypovolemia * Hypervolemia * Arterial Vasodilation * Bradycardia * PPV
93
Watch out for what two things after post decompression cardiac tamponade?
Hypertension induced * Aortic dissection * Aortic Aneurysm

Sim Lab 2 (6 decks)

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