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Week 2 Flashcards

1
Q

Describe the flow of blood through the heart

A

Enters from superior vena cava to the
R Atrium passing through the tricuspad valve into the R ventricle.
It then exits the right side of the heart through the pulmonic valve into the pulmonary artery to perfuse in the lungs. It exits the lungs (now oxygenated) through the pulmonary vein.
It enters the left atrium. It passes through the mitral valve into the left ventricle and it sent to the body by passing through the aortic valve and into the aorta

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2
Q

What is the inherent rates for the follow:

SA Node

AV Junction

Ventricle

A
  • SA Node: 60-100bpm
  • AV Junction: 40-60bpm
  • Ventricle: 20-40bpm
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3
Q

Does parasympathetic stimulation act on both the atrium and ventricles?

A

No.

PSNS stimulates the atrium only

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4
Q

Why would you place leads underneath the scapula? (2)

A

for children (kiddos are R. side heart-dominant)
OR
posterior MI suspected

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5
Q

Do the EKG lead dance

A 
Disco - Direction of the leads for the limbs
LIMB (6)
Lead I - R hand to L hand
Lead II - R hand to L leg
Lead III - L hand to L leg
AVF - left foot pos. electrode
AVR - right arm pos. electrode
AVL - left arm pos. electrode 
For extra learning fun:
CHEST (6)
V1 - aortic auscutation zone
V2 - pulmonic
V3 - erbs
V4 - left of mitral
V5 - mitral
V6 - right of mitral
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6
Q

What does the P wave indicate?

A

atrial depolarization (contraction)

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7
Q

what does the PR Interval indicate?

A

conduction delay through AV node (due to Ca ions)

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8
Q

what does the QRS complex indicate?

A

ventricular depolarization (contraction)

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9
Q

What does the QT Interval signify?

A

mechanical contraction of the ventricles (with repolarization)

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10
Q

What do we know about the T wave?

A

ventricular repolarization

inversion may indicate MI

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11
Q

What is happening with the heart during the ST segment?

A

ventricles depolarized

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12
Q

What is a U wave?

A

Occurs after T wave
caused by
- hypokalemia
- bradycardia

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13
Q

On an EKG strip:

One small box = how many seconds?

One large box = secs?

A
  • Small: 0.04 sec

- Large: 0.20 sec (1 large box = 5 small)

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14
Q

What are examples of irregularly irregular rhythms? (5)

A
  • Sinus arrhythmia
  • PAC
  • PVC
  • Afib
  • Vfib (pulse-less!)
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15
Q

What do you look at to determine rhythm on an EKG?

A

R-R intervals

if it is irregular run a CMP to check electrolytes

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16
Q

Regularly irregular rhythms include:

A
  • PAC

- PVC(bigeminy/tri/quad)

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17
Q

How do you determine the rate on an EKG

A
  • Count small boxes between two R waves
  • 1500 small boxes/minute=BPM
  • count number of beats per 6 second stripx10
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18
Q

Define Tachycardia?

A

> 100bpm

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19
Q

Define Bradycardia?

A

<60bpm

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20
Q

How is rate determined using large box distance between two R waves?

A

300, 150, 100, 75, 60, 50

ONLY WORKS for REGULAR rates*

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21
Q

If a P wave is not present before every beat what 7 things could it be

A 
Junctional rythmn
ventricular rhythm
PJC/PVC
vtach
torsades
vfib
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22
Q

A sinus rhythm consists of what on a ekg

A
  • P before every QRS in 1:1 ratio
  • Same distance between QRS
  • P waves look the same
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23
Q

You know stimulus is coming from the sinus node how?

A

When P waves are normal

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24
Q

What is a normal sinus rhythm

A
  • P before every QRS in 1:1 ratio
  • Same distance between QRS
  • P waves look the same
  • 60-100bpm
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25
Define sinus bradycardia. When are you concerned? When would you RX a pacemaker? What are symptoms of bradycardia?
<60bpm with normal P waves Concerned at <45-50bpm Pacemaker at 40bpm Sx: Lightheaded, dizzy, syncope, SOB, chest pain
26
what is sick sinus syndrome
sx of bradycardia with tachycardic episodes
27
Define sinus tachycardia. What labs might you run? What symptoms would you expect to see?
>100-150 bpm w/ normal p wave - labs: electrolytes, glucose, tsh, toxicology, cmp/cbc - Sx: palpitations, hypoTN, cyanosis, syncope, dizziness, weakness, chest pn, sob, altered mental status
28
Describe sinus arrythmia:
R-R interval shortens with inspiration, widens with expiration - pronounced in children, healthy as long as its phasic, hold breath, normalizes=good - looks wide..then shortened...then wide again
29
Premature atrial contraction (PAC) What are common sequelae for PACs? (3) what will you feel in the pulse if PAC?
- contraction is in atrium but outside SA node - See a randomly early P wave, narrow QRS, may not conduct to ventricles, irregular rhythm SEQUELAE - aflutter - afib - psvt palpate pulse: beat will come but will be weaker
30
What is the most common non-geriatric arrhythmia?
PAC
31
what are potential etiologies of PAC (6)
- emotion - fatigue - alcohol - tobacco - coffee - stimulants
32
# Define Premature Ventricular Contraction (PVC) what sx do PVCs cause? what are common sequelae? How does the pulse feel?
early beat, no p wave, wide bizarre QRS sx: asx or flip flop palpitations Seq: - can deteriorate into more frequent pvcs (couplet, bigeminy, trigemini), - V tach (3 or more beats in a row), - V Fib, - asystole pulse: weak contraction, may/may not feel the beat
33
When do you know the source of stimulus is unifocal
identical shapes, a pvs is labeled and isolated
35
When looking at QRS on EKG, when do you know you're looking at Multifocal PVC's?
when QRS are more than one shape
36
What does Bigeminal mean?
every other beat is pvc
37
What does trigeminal mean?
every third beat is pvc
38
What is a triplet?
occur in group of three
39
Three PVCs in a row =?
V-tach
39
What is the acetylcholine protocol
OLD: 1,000 mg choline +1,000 mg pantothenic acid mixed in water drank all day..people didnt like this NEW: SR choline 750mg and SR pantethine 300mg 1q8hs SR=slow release
40
Junctional beat is described as what?
Upsidedown P wave
41
What so great about Ach protocol
-neurotransmitter released in all pre and post ganglionic parasympathetic neurons - induce skeletal muscle contraction - inhibit cardiac contraction
42
What do you add to the Ach protocol if they have a lot of anxiety
- Tyrosine - 5HTP - cofactors with Lecithin and PA
43
in regards to Ach protocol why would you choose panthethine over pantethenic acid?
- frequent PVC - Elevated TG (dual benefit) - DM - low income
44
What is long QT Syndome and why is it bad? Tx:?
When the QT interval is lengthened it can be bad! - Torsade de points - SCD - Vfib - Twave alternans TX: betablockers, d-fib, electrolytes
45
Torsade de points tx: what can it lead to
rapid polymorphic ventricular tachycardia with characteristic twist of QRS around isoelectric baseline tx: IV magnesium - can degenerate into vfib
46
What is T wave alternans a risk for
sudden cardiac death (SCD)
47
Who is at risk for SCD?
- aborted cardiac arrest - Fhx unexplained sudden death - syncope - torsade de points - t-wave alternans - prolonged QTc
48
What types of drugs can cause prolonged QT
- HTN: furosemide, HCTZ - Antimicrobials: sulfa, erythromycin, ketoconazole, azithro, cipro - Electrolyte: hypo (kal,cal,mg) - Psychotropics: haloperidol, risperidone, thioridazine, tricyclics, citalopram, sertaline - Celexa
49
What is the rule about celexa in regards to long QT intervals?
Never give doses above 40mg/day | -inhibits fast acting Na channels
50
What is a PCP's responsibility regarding long QT
check prior to drug RX for long QT - check again when medication is steady state - RUN THE EKG
51
how many half-lives of a medication does it take to reach steady state concentrations?
5 half-lives
52
What is normal BP after 5 minutes resting for Age <60 Age >60
<60: under 140/90 mmHg | >60: 150/90mmHg
53
When assessing the PMI what is important to note
- Location: 5th interspace MCL - Diameter: 4cm or less - Duration: brief, never passes midsystole - Amplitude: force
54
If the PMI is laterally displaced or enlarged think what?
LCHF
55
What is a thrill? | What is a heave?
Thrill: palpable vibration associated with an audible murmur Heave: sustained apical impulse beyond mid systole
56
Name 5 irregularly irregular rhythms
- PAC - PVC - Afib - AV Block - Sinus arrhythmia
57
What are PACs? Can you feel these on the pulse?
Early atrial beat feels normal strength due to normal cardiac output you can feel this on the pulse!
58
What are PVCs? How does the pulse palpate?
Early ventricular beat | pulse feels weak due to decreased cardiac out
59
Tell me about A-Fib, how do you assess HR with A-Fib?
completely erractic pulse | must auscultate at apex for 60 seconds to accurately assess HR
60
Tell me about AV Block
second/third degree may feel like random dropped beat
61
Does V fib have a pulse
NO | cardiac arrest
62
List the three types of premature beats
PAC PJC PVC
63
What is pulses biferens
- twice as striking, dicrotic pulse, systolic - second pulse is during diastole from closure of aortic valve - common with AS, AI, HOCM
64
Pulsus alternans: does it alternate with breath? What is it a sign of?
alternation of strong and weak arterial pulses despite RRR. BP varies >20mm from one check to the next DOES NOT alternate with breath Sign of severe left ventricular dysfunction... the DEATH RATTLE dun dun dun
65
What is Pulsus Paradoxus? | when is it seen?
exaggerated fall in systolic BP during quiet inspiration- cannot palpate pulse on inspiration - cardiac tamponade - constrictive pericarditits, - asthma COPD - Restrictive cardiomyopathy, - severe PE - hypovolemic shock
66
What is Pulses paradoxicus? | what can cause it?
increase in pulse strength/BP during inspiration (normally falls) -PE, COPD, rCHF, emphysema, asthma
67
What is Pulsus parvus?
Low volume, small weak pulse shock, myocardial disease, AS, pericardial dz, cardiac failure, cardiomyopathy
68
What is Pulsus Tardus?
delayed systolic peak due to obstruction of left ventricular ejection, slow rise escalated under finger
69
Pulses parvus et Tardus Carotid Pulse
carotid pulse is reduced and delayed
70
Corrigan's Pulse
bounding and quickly collapsing pulse of aortic regurg, can see in carotids and in bobbing head
71
Define JVD What is it gold standard for? What else can JVD be indicative of?
the highest point of pulsation for the internal jugular vein is 3-4cm above the sternal angle Gold standard: cardiac cause of edema (CHF) - rCHF - Constrictive Pericarditis - SVC obstruction - Restrictive cardiomyopathy - Tricuspid regurgitation
72
Hepatojugular Reflux how is it preformed What does it indicate
1cm** or more rise in JVD 3-4cm above sternal angle. Press firmly on partially inflated BP cuff 20-30mmHg for 15-30sec 80% sensitive and specific for Chronic R and L CHF
73
What is S1 What is S2
s1: closure of mitral/tricuspad-systole s2: closure of aortic/ pulmonic valve-Diastole
74
Aortic valve closes before or after the pulmonic valve in S2
Aortic valve (L) closes before pulmonic vale (R)
75
What is an S1 split What is a physiologic S1 split
mitral and tricuspad do not close togehter, heard at tricuspid area, as if it is all the time or not. yes: delay of pulmonic closure Physiologic :split: does not vary with respiration
76
List the etiology for the following S1 splits: - Fixed - Intermittent - Fixed or Intermittent
- Fixed: #1RBBB, ASD, - Intermittent: PVC (ectopic foci-->lack of perfusion-difference in ventricular timing) - Fixed or Intermittent: V-tach
77
What is a physiologic S2 split
split on inspiration dt delayed pulmonic valve closure
78
Causes of pathologic fixed S2 split
ASD, Mitral Regard, Pulmonic Stenosis, RVF
79
If you hear the S2 split more on inspiration than expiration think: expiration > inspiration:
Inspiration > Expiration: RBBB Expiration > Inspiration: LBBB
80
S3 gallop
- Diastolic heart sound post s2 | - Dt rapid filling against a non-compliant ventricle- death rattle
81
s4 gallop
diastolic heart sound pre s1 | -dt sudden ventricular distention during atrial systolic contraction
82
When would you use the left lateral decubitus position?
- obese patients/difficult to hear murmurs | - Best to hear mitral and extra sounds
83
When would you use sitting forward
Aortic stenosis
84
What is QTPILL and what is it used for
``` Quality Timing Pitch Intensity Location Length ```
85
Describe and associate with the correct murmur - Harsh: - Blowing:
Harsh: high pitched, stenotic murmurs (AS/PS) | Blowing: Low pitch, hollow tunnel=LEAK TR, MR, AR, PR
86
Describe and associate with the correct murmur - Rumbling - Musical
Rumbling: through stenosis-MS, TS Musical: MVP
87
Do stenotic valves have higher or lower pitch murmurs
Steonic: lower pitch, wider openings
88
High pitch murmurs listen with the (bell/diaphragm)
diaphragm | Regurge/S2 murmurs
89
Low pitch murmurs listen with the (bell/diaphragm)
Bell: MS/TS, S1,S3, S4
90
medium pitch murmurs include
PS/AS
91
List the intensity levels What is the name of this?
Levine System for Grading Intensity of Murmurs - 1/6: soft, intermittent, need to concentrate - 2/6: audible immediately on every beat - 3/6: loud, no thrill - 4/6: loud,thrill - 5/6: heard by placing edge of diaphragm over chest - 6/6: heard with stethoscope above surface
92
Inspiration as an auscultation maneuver creates what? -Increase intensity of what sounds?
Increases RA return, delays pulmonic valve closure, earlier closure of aortic valve -Increase intensity of R. Heart sounds(PS/TS)
93
Expiration as an auscultation maneuver creates what? -Increase intensity of what sounds?
Increased LA return Increases L heart sounds
94
Isometric Hand Grip as an auscultation maneuver creates what? -Increase intensity of what sounds?
-Increases peripheral resistance and blood in L. Ventricle -Increases; Regurg Murmurs(AR/MR) -Decreases AS/MVP
95
Valsalva as an auscultation maneuver creates what? -Increase intensity of what sounds?
- Decrease venous return, left ventricular volume - Increases: HOCM+MVP ``` -Decreases: Most murmurs (MS/AS) ```
96
PLR/Squatas an auscultation maneuver creates what? -Increase intensity of what sounds?
- increaes venous return to the heart and L.ventricular volume - Increases: AS/MS Decreases: HCOM/MVP
97
Typical Angina Unstable Angina "E" triggers of angina
Typical: substernal, rest/nitroglycerine <2-15 minutes Unstable: new unsent,
98
Thin MI when:
Associated with diaphoresis N/V, "impending doom" -Not relieved by rest, intro
99
Sx of : Aortic Stenosis Aortic Dissection Pericarditis
Stenosis: severe, syncope, angina, DOE. Crescendo, decrescendo Dissection: Rapid onset, maximum intensity, "tearing", radiates to back, urgent referral, order Cxr/D-dimer Pericarditis: sudden, sharp, pleuritic pain, relieved leaning forward, radiation to neck
100
5 questions to ask all patients with chest pain
1. Worse on exertion? 2. is it NOT reproducible from palpation 3. Do you think its from your heart? 4. Age: 5. Hx of vascular disease Each question scores 1 points
101
If they have chest pain + DOE rule out what?
CAD, CHF, COPD see if its better with nitro
102
Central vs Peripheral Cyanosis
Central: Altitude sickness, pulmonary edema, COPD, PE Peripheral: raynauds, chf, shock, outflow tract obstruction (AS/HCOM)
103
DDX for Palpitations with: Flip/flop: Flutter: Tachycardia:
Flip Flop: PAC/PVC Flutter: Aflutter, Afib, frequent PAC/PVC Tachycardia: sinus tachycardia, PAT, PSVT
104
B/L lower extremity edema U/L lower extremity edema
B/L: CHF or chronic kidney dz U/L: DVT

Cardiology (8 decks)

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