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What does SVR measure?
After-load of the left side of the heart
What are the normal values for monitoring PAP pressures?
How does Angiotensin II impact the cardiovascular system?
Increasing both preload and afterload by vasoconstriction (afterload) and increasing urinary retention (preload)
Your patient is experiencing left ventricular diastolic dysfunction. What should therapy be focused on?
Increasing preload; impaired filling of the ventricles equals inadequate filling pressures; increasing preload increases filling pressures
Your patient is experiencing right ventricular diastolic dysfunction. What should therapy be focused on?
Increasing force of contraction; ventricle is having a problem pumping forcefully; positive inotropic agents i.e. Dopamine
The patient's peripheral A-line is showing a very sharp waveform with readings that appear jagged and exaggerated. This may be due to:
Overdampened waveforms can do what to blood pressure readings?
Your patient's PA waveform has suddenly changed to resemble a low amplitude rolling waveform. This is most likely due to:
An inadvertent advance to wedge
When assessing CVP or PAWP pressures on a mechanically ventilated patient, the pressures should be assessed at:
The end of exhalation
The dicrotic notch on the PA waveform indicates:
Closure of the pulmonic valve
The patient's PA catheter is exhibiting a large, well defined waveform with an obvious "notch" on the left side of the waveform. The distal tip is most likely in the:
A patient in early shock most probably has which acid-base imbalance?
Treatment of pancreatitis would NOT include...
Morphine for pain- it can increase spasms at sphincter of Oddi
The clotting cascade can be triggered through an extrinsic pathway. The triggering mechanism is the release of?
Your patient presents with the following: CVP 2, CI 6.4, PA S/D 34/16, wedge 7 and SVR 400. What is your diagnosis?
What would the blood test BNP evaluate a patient for?
Congestive heart failure
What are your primary medications for a patient presenting with a suspected AAA?
Nipride and Beta Blockers
The balloon has dislodged when treating your IABP patient. Which is the most common site that will be affected?
During transport you notice rust colored "flakes" in the IABP tubing. This indicates...
During transport you experience a complete IABP failure. You should...
Cycle the balloon manually every 30 minutes regardless of timing to prevent formation of clots
Acute respiratory failure is defined as:
pO2 <60 mmHg and pCO2 >50 mmHg
A sign that can indicate hyperventilation and/or hypocalcemia is:
What measurements are indicators of right-side preload?
- Right atrial pressure (RAP)
- Central venous pressure (CVP)
- Pulmonary vascular resistance (PVR)
What measurements are indicators of left-side preload?
- Left atrial pressure (LAP)
- Pulmonary artery "wedge" pressure (PAWP)
- Pulmonary wedge pressure (PWP)
- Pulmonary capillary wedge pressure (PCWP)
- Pulmonary artery occlusive pressure (PAOP)
- Systemic vascular resistance (SVR)
What measurements are indicators of pressure in the pulmonary artery?
- Pulmonary artery pressure (PAP)
- Pulmonary artery systolic (PAS)
- Pulmonary artery diastolic (PAD)
What measurements are indicators of afterload?
- Cardiac Index (CI)
- Cardiac Output (CO)
- Stroke Volume (SV)
- Left ventricular end-diastolic pressure (LVEDP)
- Left ventricular end-diastolic volume (LVEDV)
How do you calculate Cardiac Output?
SV x HR
How do you calculate SV?
How do you calculate ejection fraction?
SV divided by EDV
What is normal ejection fraction?
- Most important predictor of prognosis
How do you calculate CPP (coronary perfusion pressure)?
- DBP - PAWP
- Normal value 50-60
- Can substitute PAD if no wedge
What is normal wedge?
What is normal CVP?
What is normal PVR?
What is normal PAS?
What is normal PAD?
What is normal cardiac index?
2.5 - 4.3 L/min
What is normal SVR?
What types of shock should you consider if your SVR is low (<800)?
Vasodilatory or distributive
If your SVR is low and your CI is high, what type of shock do you have?
If your SVR is low and your CI is low, what is the next thing to look for?
- If tachycardic, you have anaphylactic shock. If normal or low HR, you have neurogenic shock.
What types of shock should you consider if your SVR is high (>1200)?
Hypovolemic, Cardiogenic, or RV AMI
If your SVR is high and your CVP is <2, what kind of shock do you have?
If your SVR is high and your CVP is normal or low, what condition do you have?
If your SVR is high and your CVP and wedge are high, what kind of shock do you have?
What is the mechanism of action of ACE inhibitor drugs?
Vasodilation, thus decreasing afterload
What is the mechanism of action of Angiotenson II Receptor Blockers (ARBs)?
Decrease systemic afterload, decreasing the workload of the LV
What is the most common insertion site for a PAC?
Right internal jugular
What does PAC stand for?
Pulmonary artery catheter, aka Swan-Ganz catheter
On CXR, where should tip of PAC be seen if placed properly?
2nd or 3rd intercostal space
What is the maximum amount of air that can be placed in balloon port (red port) for a wedge?
If you can only monitor one port on a PAC, which port should you monitor?
Distal (PA) Yellow port
What does transducer leveling do?
Eliminates the influence of hydrostatic pressure on the transducer
When should transducer leveling be performed?
After every change in patient position
What axis should transducer leveling be performed at?
Phlebostatic axis, where the nipple line and mid-axillary line meet at approximately fourth intercostal space
What can cause catheter whip?
High blood pressures, length of tubing, or movement of the catheter tip
What does an overdampened waveform present like on the monitor?
- Slow return to baseline
- Waveform appears "squeezed down" from too much pressure
What can cause overdampened waveforms?
- Overly compliant tubing
- Air bubbles
- Catheter kinks
- Low flush bag pressure (need minimum 300 cc)
What does an underdampened waveform present like on the monitor?
- More than two oscillations after fast flush test
- Exaggerated waveform
What can cause underdampened waveforms?
- Non-compliant tubing
- Increased vascular resistance
- High systolic and low diastolic pressures
- Loose connections
- Air in the system
- Altitude changes
In a dampened waveform, what should you always do first to try to correct?
Aspirate, do not flush in case of clots
What waveform group has a dicrotic notch?
What waveform group has a, c, v waves and x and y descent?
What unique notch do ventricular waveforms have?
Anacrotic notch that correlates with QRS
What measurements do Atrial waveforms read?
- Preload measurements
What measurements do Arterial waveforms read?
In an atrial waveform, what does the a-wave indicate?
Atrial contraction (prior to onset of QRS)
In an atrial waveform, what does the c-wave indicate?
Ventricular contraction and closure of tricuspid valve (occurs within the QRS)
In an atrial waveform, what does the x descent indicate?
Atrial relaXation (occurs after the QRS)
In an atrial waveform, what does the v-wave indicate?
PassiVe atrial filling (occurs just after T-wave)
In an atrial waveform, what does the y descent indicate?
Atrial emptYing and opening of the tricuspid valve
How do you manage an inadvertent wedge position?
- Check balloon, make sure it is deflated
- Have patient cough forcefully
- Change position of patient (elevate head slightly)
- RAPID TRANSPORT - DO NOT PULL CATHETER BACK
What does it mean if you have a wedge reading of 15-18?
Ideal wedge in CHF patient
What does it mean if you have a wedge reading of 18 or less than 12?
What does it mean if you have a wedge reading of 20?
Mild pulmonary congestion
What does it mean if you have a wedge reading of 25?
Moderate pulmonary congestion
What does it mean if you have a wedge reading of 30?
Severe pulmonary congestion
What could large v-waves indicate on wedge tracing?
Mitral valve regurgitation
What does the dicrotic notch on the PA waveform indicate?
Closure of the pulmonic valve
What are some causes of elevated PAP?
- Increased PVR
- Left to right shunts (patent ductus arteriosus)
- Left ventricular failure
- Mitral regurgitation and stenosis
What does the dicrotic notch on the A-line waveform indicate?
Closure of the aortic valve
What does the highest point of the A-line waveform correlate with?
Systolic pressure; T-wave on EKG
What does the lowest point of the A-line waveform correlate with?
Diastolic pressure; end of QRS on EKG
What is Cullen's sign and what does it indicate?
- Bruising around umbilicus
- Can indicate pancreatitis, peritoneal or retroperitoneal hemorrhage
What is Grey-Turner's sign and what does it indicate?
- Bruising to the flank area
- Can indicate pancreatitis and retroperitoneal hemorrhage
What is HalsteAd's sign and what does it indicate?
- Marbled abdomen
- Can indicate necrotic pancreas
What is Halsted's sign and what does it indicate?
- Breast discoloration
- Can indicate breast cancer
What is the primary treatment for hepatic encephalopathy?
Evacuate any blood present in the gut via OG/NG tube to decrease ammonia levels
What is the treatment for esophageal variceal hemorrhage?
Vasopressin and S-Blakemore tube
What structure defines lower versus upper GI?
The Ligament of Treitz - suspensory ligament of the duodenum
What is Markel's sign and what does it indicate?
- Rebound tenderness on palpation
- Can indicate peritoneal irritation or appendicitis
What is Rovsing's sign and what does it indicate?
- Referred pain to RLQ when LLQ is palpated
- Can indicate appendicitis
What is Aaron's sign and what does it indicate?
- Referred pain felt in epigastric region upon continuous firm pressure over McBurney's point (iliac to umbilicus, form a v)
- Diagnostic for appendicitis
What is Psoas sign and what does it indicate?
- Patient lying on side hyperextension or flexion of hip elicits RLQ pain
- Can indicate appendicitis
What is Kehr's sign and what does it indicate?
- Referred shoulder pain while supine
- Spleen injury/rupture (left shoulder)
- Ectopic pregnancy (either shoulder)
What is Balance sign and what does it indicate?
- Dullness to percussion of LUQ with a shifting dullness to RUQ, both due to blood
- Can indicate spleen injury or rupture
What is Murphy's sign and what does it indicate?
- Pain on inhalation or coughing when RUQ is palpated
- Inflammation of gallbladder; diagnostic of cholecystitis
What is Linea Nigra and what does it indicate?
- Darkening "line" of skin from umbilicus to pubic symphysis
- Indicates pregnancy
One unit of PRBC's equals approximately ___ 330 mL and increases H/H by ____%.
330 mL and 1/3 or 33%
What is the pediatric dose for PRBC's?
What is the universal blood donor type?
What is the universal recipient blood type?
What is FFP and what is it useful in correcting?
- Fresh Frozen Plasma
- Volume expander or to increase clotting factors
- Corrects Warfarin induced hemorrhage or toxicity, along with Vit K
What is cryoprecipitate and what types of conditions is it used for?
- Corrects low fibrinogen levels
- Used in DIC, Hemophilia A and Von Willebrand's disease (Factor VIII)
What are the four types of blood transfusion reactions?
- Hemolytic - short onset
- Anaphylactic - 30 min onset, treat with epi
- Febrile - 30-90 min onset
- Circulatory overload - can occur anytime, treat with Lasix
What is the problem in Hemophilia A patients?
Cannot form a stable fibrin clot
What is the problem in Hemophilia B patients?
- AKA Christmas disease
- Prolonged partial thromboplastin (PT) times
What is the problem in Von Willebrand's patients?
Defective platelet adherence; cannot form platelet plugs
What is the drug of choice for treatment of vasodilatory shocks?
- Levophed (Norepinephrine)
- Increases vascular tone through alpha-adrenergic receptors
What are the 7 P's of Spinal Cord injury?
- Ptosis, Pinpoint pupils
What is the problem in a patient with Graves disease?
- Increased levels of thyroid hormones
- Avoid ASA - releases T3 and T4 hormones
- Treatment is steroids (Dexamethasone)
- Can present with tremors, weight loss, AFib, expothalmus, goiter
What is the problem in a patient with myxedema coma?
- Treatment is Levothyroxine
- Can present with coarse hair, fatigue weight gain
What is the main problem in a patient with hypoparathyroidism?
Hypocalcemia - PTH regulates calcium levels
In a patient with a head injury, you note extreme urinary output with very low specific gravity. What is your initial treatment of this patient?
- Aggressive fluid replacement and vasopressin
- Diabetes Insipidus is often caused by head injury, due to a deficiency of ADH from posterior pituitary gland
- Can result in hypernatremia (possible SZ) and hypokalemia if untreated
What is the main problem in SIADH?
- Overproduction of ADH which can be caused by anything that interferes with renal excretion of water
- Can result in dilutional hyponatremia and hypokalemia
- Treatment is to restrict fluids and correct electrolytes - hypertonic 3% NS
What is Cushing's Disease?
- Increased levels of cortisol, usually caused by an anterior pituitary tumor
- Presents with moon face, buffalo hump, upper body obesity with thin extremities, hypertension
- Treated with steroids
What is Addison's Disease?
- Acute Adrenal Insufficiency - Adrenal glands not producing enough cortisol
- Presents with asthenia, severe fatigue, weight loss, darkening of skin, hypotension
What drug is to be used with extreme caution in Addison's disease patients?
Etomidate - refractory hypotension 8-10 hours later
What is Conn's Syndrome?
- AKA Hyperaldosteronism
- Usually caused by adrenal tumor known as pheochromocytoma
- Can lead to hypokalemia, hypernatremia, hypertension, alkalosis
- Treated with Spironolactone (works as aldasterone antagonist)
What is the treatment for HHNK?
- Aggressive fluids
- Short acting/regular insulin
What lab value needs to be closely monitored in DKA patients being treated with insulin?
Potassium - If falls below 3.3, insulin needs to be stopped and K+ administered to correct hypokalemia
What EKG finding should force you to automatically consider RVMI?
ST elevation of 1 mm or greater in aVR
If a Q wave greater than 25% of the height of the QRS with ST elevation, you should...
Suspect acute infarct
If a Q wave is present with ST depression...
It is indeterminate
If a Q wave is present with no ST changes...
There is an old infarct
If you suspect an inferior infarct, what coronary artery do you expect to be affected?
If you suspect a lateral infarct, what coronary artery do you expect to be affected?
If you suspect a septal or anterior infarct, what coronary artery do you expect to be affected?
If you suspect a posterior infarct, what coronary artery(s) do you expect to be affected?
RCA and Circumflex
What are three things you should look for if you suspect a Posterior infarct?
- Progressive, tall R waves
- Slight ST elevation in V6
- Reciprocal changes in V1-V3
What can U waves indicate on EKG?
What is a common complaint from patients suffering from digitalis toxicity?
In a patient who has undergone a heart transplant, what drug would be useless in treatment of symptomatic bradycardia?
Atropine - Vagus nerve is not re-transplanted with heart
What does FAEDE stand for?
- External Pacer
- Dopamine/Dobutrex drip
- Epinephrine drip
What drugs are contraindicated in the patient with WPW?
- Drug of choice: Amiodarone
What is BNP?
- Brain Natriuretic Peptide
- Assists in diagnosis of CHF
- >100 positive, >500 severe
What position should a CHF or ICP patient be loaded in a fixed-wing aircraft?
Head forward - diminishes increased pressures on takeoff
What are some hallmarks of pulmonary edema on CXR?
- Fluffy margins
- Kerley B lines
- Pleural effusions
What presentation does ARDS have on CXR?
- Ground glass
- No Kerley B lines
What presentation does pericardial effusion have on CXR?
Enlargement of cardiac silhouette with characteristic water bottle appearance
What does pericardial effusion present with on 12-lead EKG?
Electrical alternans - increase and decrease in amplitude of R waves
If PAWP = PAD, what should you suspect?
What is Dressler's syndrome?
- Secondary form of pericarditis two to three weeks after injury to the heart or pericardium
- Presents with fever, pleuritic pain, and pericardial effusion
What are Janeway lesions?
- Raised red lesions seen on fingers, palms, and soles of feet - painless
- Indicate Endocarditis
What are Osler's Nodes?
- Painful raised reed lesions seen on fingers, palms, and soles of feet
- Indicate Endocarditis
What is the most common cardiac cause of clubbed fingers?
Congenital cyanotic heart disease
What is a cause of clubbed fingers aside from congenital heart disease and chronic hypoxia?
Subacute bacterial endocarditis
What does an aortic dissection present with on CXR?
- Mediastinal and/or aortic widening
- Left pleural effusion
What is Hill's Sign?
- Difference in SBP greater than or equal to 20 mmHg between brachial and popliteal BP
- Indicates acute aortic insufficiency
Where does the tear occur in a AAA?
The tunica intima
What is Marfan's syndrome?
- A connective tissue disorder characterized by joint laxity, scoliosis, long upper extremities
- Associated with dilation of the ascending aorta
What is Turner's syndrome?
- Missing X chromosome (only occurs in females)
- Webbed necks is most identifiable physical characteristic
How do we manage an aortic dissection?
- 2 large bore IVs, restrict fluids unless patient is hypotensive
- Nitroprusside to lower BP to 100-110 mmHg systolic
- Beta blockers
- Pain analgesics
- Definitive treatment is surgery
What is Virchow's Triad?
- Flushed skin
- Indicates DVT
What is the treatment for DVT?
- Elevate extremity
How much can IABP augment cardiac output?
When does the IABP balloon inflate?
During diastole, with the closure of the aortic valve
What is the main benefit to placing an IABP?
What does the dicrotic notch on a balloon pump timing strip indicate?
Closure of the aortic valve
What is the primary indication for IABP placement?
What is the primary contraindication for IABP placement?
Severe aortic insufficiency
When using the ECG to trigger an IAB, what is the synchronization point for balloon inflation?
With the T-wave
When using an A-line to trigger an IAB, what is the synchronization point for balloon inflation?
With the dicrotic notch on the A-line waveform
Where should the distal tip of the IAB be seen on CXR?
At the level of the 2nd or 3rd intercostal space
Where should the proximal end of the IAB be?
Above the renal artery
Where should the distal end of the IAB be?
In the descending aorta, just distal to the left subclavian artery
If your patient experiences a distal dislodgement (most common) of the IAB, which site will be affected?
Left radial artery
If your patient experiences a proximal dislodgement of the IAB, which site will be affected?
- Renal arteries, resulting in decrease in urine output
- Possibly also the femoral arteries
Acute respiratory failure is defined as:
pO2 <60 mmHg and pCO2 >50 mmHg
What are some causes of respiratory acidosis?
- Airway obstruction
- CNS depressant medications (hypoventilation)
- Myasthenia gravis
- Pickwickian syndrome
What are some causes of respiratory alkalosis?
- Excessive mechanical ventilation
- Third trimester pregnancy
What are some causes of metabolic alkalosis?
- Vomiting, NG suction
- Thiazide or loop diuretics
How do you calculate Anion Gap?
- Na - (Cl +HCO3) = AG
- Normal is 12 (+ or - 4)
What is the mnemonic for differential diagnoses of metabolic acidosis?
What does MUDPILERS stand for?
- Propolene glycol
- Lactic acidosis
- Ethylene glycol
- Renal failure/Rhabdomylosis
- Salicylates/Starvation ketoacidosis
What is the normal value for K+?
3.5 to 5.0
What is the normal value for Ca?
8.8 - 10.4
What is the normal value for Mg?
What is the normal value for Na?
What is the normal value for glucose?
What is the normal value for BUN?
What is the normal value for Creatinine?
What does creatinine measure?
What is the normal value for CK/CPK?
What does CK/CPK measure?
Muscle enzymes (rhabdo)
What is the normal value for ammonia in an adult?
What is the normal value for ammonia in a pediatric?
What is the normal value for BNP?
What is the normal value for WBC?
4.5-10.5 (peds slightly higher)
What is the normal value for Hgb?
What is the normal value for Hct?
What is the normal value for platelets?
If your pCO2 is <35 mmHg in a ventilated patient, what should you do?
- Decrease tidal volume
- Decrease RR
- Consider sedation/analgesia
If your pCO2 is >45 mmHg in a ventilated patient, what should you do?
- Increase ventilation first by increasing tidal volume
- Then increase respiratory rate
What is typical tidal volume for an adult patient?
What is the oxygen formula?
PSI x cylinder divided by liter flow = time of O2 remaining
What is the formula for the oxygen required at altitude?
FiO2% x barometric pressure prior to ascent divided by barometric pressure at altitude = % of O2
How does asthma present on CXR?
- SQ air upper lobes
- Hyperinflated lungs
- Elongated heart
- Pneumomediastinal air "leaks"
How does emphysema present on CXR?
- Large, hyperinflated lungs
- Low set diaphragm
- Increased AP diameter
- Vertical heart
- Increased retrosternal air
How does Chronic Bronchitis present on CXR?
Bronchovascular structures have irregular contours - only finding
Which toxicity presents with a profound anion gap?
What is basic treatment of a snakebite?
- Immobilize affected limb below level of heart
- NO ICE
- Obtain fibrinogen levels and CMP
What is basic treatment of a spider bite, scorpion sting, or hymenoptera sting?
- Ice, analgesia
- Immobilize affected area
- Watch for anaphylaxis
What is the first line treatment for Rocky Mountain Spotted Fever?
What would you like to do?
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