Health Assessment Quiz 3 (Cardiac)

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Health Assessment Quiz 3 (Cardiac)
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2013-05-30 23:14:07
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BC CRNA Health Assessment Quiz
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  1. History questions for peripheral vascular disease
    • Pain in arms or legs
    • Intermittent claudication – pain in legs when walking
    • Cold, numb extremities, pallor in legs, hair loss
    • Swelling in calves, legs or feet
    • Color changes in fingertips, toes in cold weather
    • Swelling with redness or tenderness
    • Smoking Hx
  2. Arteries anatomy and size vary according to _________?
    their distance from the heart
  3. Arterial pulses are palpable when....
    the artery lies close to body surface
  4. Head and neck arteries are:
    temporal and carotid arteries
  5. Name the three arterial pulse locations in the arm
    • Brachial: at bend of elbow just medial to biceps tendon
    • Radial: lateral flexor surface at wrist 
    • Ulnar: medial flexor surface (overlying tissues may obscure)
  6. Where are the arterial pulse locations in the leg?
    • Femoral: below inguinal ligament
    • Popliteal: passes medially behind the femur; palpable behind knee
    • Dorsalis pedis: dorsum of foot; lateral to extensor tendon of big toe
    • Posterior tibial: behind medial malleolus of ankle
  7. Amplitude of arterial pulses
    • 3+  Bounding
    • 2+  Brisk, expected (normal)
    • 1+  Diminished, weaker than expected
    • 0  Absent, unable to palpate
  8. Veins are
     thin-walled and highly distensible
  9. Deep veins carry:
    ~90% venous return from lower extremities and are well-supported by surrounding tissues
  10. Tell me about superficial veins
    • Subcutaneous with poor tissue support
    •  - Include great saphenous and small saphenous veins
    •  - Anastomotic veins connect two saphenous veins
    •  - Perforating veins connect superficial (saphenous) system with deep system
  11. Veins have ___ -____ valves, why?
    Propel blood toward heart, preventing pooling, venous stasis, and backward flow
  12. Describe a physical exam of the peripheral vascular system
    • Inspection – size, shape, note color, edema, ulcerations, venous pattern
    • Palpate for temperature, edema-  is it pitting, texture, grade pulses
    • Assess is there Arterial vs Venous Insufficiency
    • Special tests 
    • ¤Allen Test
    • ¤Homan’s Sign
    • ¤Doppler
  13. Raynauds
  14. lymphadenopathy
  15. vericose veins
  16. _________ Murmurs are associated with forward flow through the valves and have a crescendo- decrescendo pattern ie Aortic Stenosis
    Ejection
  17. ______ Murmurs occur when the blood is forced backward in to the atrium and have a pansystolic pattern ie Mitral Regrugitation
    Regurgitant
  18. _____ Murmurs – Occur between S1 and S2 – think contracting phase. They are either ejection or regurgitant murmurs
    Systolic
  19. ____  murmurs occur between S2 and S 1- think filling phase & are almost always indicative of heart
    disease
    distolic
  20. When taking a cardiac history, what do you include?
    • Rheumatic fever
    • Heart murmur
    • Risk factors for coronary artery disease (CAD)
    • Family history of CAD
    • -Hypertension
    • -Diabetes
    • -Tobacco use
    • -Dyslipidemia
    • Functional, Psychologic, Social and Economic Status
    • Clinical manifestations of heart disease
  21. What are some clinical manifestations of cardiac disease?
    • Chest pain
    • Dyspnea
    • Palpitations
    • Fatigue and decreased exercise tolerance
    • Syncope
    • Edema
    • Cyanosis
  22. What causes chest pain and what are the types?
    • *Supply‐demand mismatch
    • ¨Angina Pectoris
    • ¨Atypical Angina
    • ¨Angina Equivalents
    • ¨Unstable angina
    • ¨Non‐ischemic chest pain
  23. What is classic angina pectoris?
    • ¨Quality
    • ¤Oppressive feeling, pressure, tightness,  burning in precordium
    • ¨Duration
    • ¤5‐15 minutes
    • ¨Provocation
    • ¤Triggered by exercise or excitement
    • ¤Relieved with rest or nitroglycerin (NTG)
  24. What is atypical angina?
    ¨Atypical angina‐2/3 classic components
  25. What is non-ischemic chest pain?
    • ¤Pleuritic
    • ¤Fleeting¤Localized (1 finger localization)
  26. What is unstable angina?
    • ¤New onset
    • ¤Crescendo pattern
    • ¤Resting angina
  27. What do we need to know about dyspnea?
    • ¨On exertion (DOE)
    • ¨Orthopnea (worse lying flat)
    • ¨Paroxysmal nocturnal dyspnea (PND)
    • ¨Angina Equivalent (symptoms of CV disease is SOB)
    • ¨Differentiate from noncardiac dyspnea
    • ¤Pulmonary disease
    • ¤Anemia
    • ¤Deconditioning
  28. What do we need to know about palpitations?
    • ¨Awareness of heart beat
    • ¨Associated symptoms
    • ¤Lightheadedness
    • ¤Angina
    • ¤Dyspnea
    • ¤Neurologic symptoms (syncope)
    • ¨Provocation (coffee brings it on..etc)
  29. Tell me about edema
    • ¨Symmetrical?
    • ¨Neck vein distention?(JVD)
    • ¨Pulmonary congestion?
    • ¨Evidence for other volume overload states?
    • ¤Renal disease
    • ¤Hepatic disease
    • ¤Low oncotic
    • pressure
  30. What kind of things do you ask about regarding the patients functional status?
    • ¨Routine activities
    • ¨Exercise program
    • ¨Nature and requirements of job
    • ¨“How far can you walk on level ground?”
    • ¨“How many flights of stairs can you climb?”
  31. What are you looking for BEFORE the cardiac exam?
    • ¨General appearance
    • ¨Vital signs
    • ¨Maybe clues to presence of cardiac disease
    • ¨Abnormal heart rate or rhythm
    • ¨Abnormal BP
    • ¤Abnormal pulses
    • ¤Respiratory difficulty
    • ¤Skin findings
  32. How do you take VS "by the book"
    • ¨VS in each arm
    • ¨Supine and erect
    • ¨Timing and amplitude of arterial pulses
    • ¤Parvus and tardus
    •    --On palpation, pulse is weak/small (parvus)
    • & late (tardus)
    • ¤Compare upper & lower extremity
    • Pulse pressure
    • “Paradoxical pulse”
  33. Getting a BP:
     ¨Cuff should fit snugly around the arm, with its
    lower edge at least __ inch above the antecubital space
    ¨Width of the cuff ‐ at least __% of the
    circumference of the limb to be used
    ¨Rubber bag long enough to extend at least ___ around the limb
    • 1 inch
    • 40%
    • halfway (10" in adults)
  34. How do you get a BP in a lower extremity?
    ¨With the patient lying on the abdomen, an 8‐inch wide cuff should be applied with the compression bag over the posterior aspect of the mid‐thigh and should be rolled diagonally around the thigh to keep the edges snug against the skin

    ¨Auscultation should be carried out in the popliteal fossa
  35. A thrusting apex exceeding 2 cm in diameter suggests ________
    left ventricular enlargement
  36. Systolic retraction of the apex may be visible in cases of __________
    constrictive pericarditis
  37. Normally, cardiac pulsations are not visible lateral to the __________
    midclavicular line
  38. How do you do the palpation portion of your cardiac exam?
    • ¨Use the fingertips or the area just proximal to them
    • ¨Timed with the simultaneously palpated carotid pulse or auscultated heart sounds
    • ¨Chest completely exposed and elevated to 30 degrees
    • ¨Both supine and in the partial left lateral decubitus positions
  39. Rotating the patient into the left lateral decubitus position with the left arm elevated over the head causes the heart to move laterally and increases the palpability of both normal and pathological thrusts of the_____
    left ventricle
  40. The subxiphoid region, which allows palpation of the _______, should be examined with the
    tip of the index finger during held inspiration
    right ventricle
  41. What is  normally produced by left ventricular contraction and is the lowest and most lateral
    point on the chest at which the cardiac impulse can be appreciated?
    PMI
  42. How (where) can you normally palpate the PMI or LV impulse?
    • medial and superior to the intersection of the
    • left midclavicular line and the fifth intercostal space
    • and is palpable as a single, brief outward motion
  43. TRUE OR FALSE. PMI is not palpable
    in 50% of adults > 50 yo
    TRUE
  44. TRUE or FALSE. In the left lateral decubitus position, a PMI diameter of more than 2 cm is an accurate sign of left ventricular enlargement
    FALSE. More than 3cm is a sign of LV enlargement
  45. What is LV heave or lift and when do you see it?
    • Concentric hypertrophy
    • ¤left ventricular dilatation without volume overload

    Sustained outward movement of area larger than 2 to 3 cm in diameter
  46. What is RV heave or lift and when do you see it?
    • ¨Palpable anterior systolic movement (replacing
    • systolic retraction) in the left parasternal region
    • ¤felt by the proximal palm or fingertips
    • ¤patient supine

    • ¨Right ventricular enlargement
    • ¨Pulmonary HTN &  increased pulmonary blood flow frequently produce a prominent systolic pulsation of the pulmonary trunk in the second intercostal space just to the left of the sternum
  47. What are thrills and how do you assess them?
    ¨The flat of the hand or the fingertips usually best appreciate thrills, which are vibratory sensations that are palpable manifestations of loud, harsh murmurs having low‐ to medium‐frequency components
  48. The topographical areas for auscultation:
    • ¤Cardiac apex
    • ¤Left and right sternal borders interspace by interspace
    • ¤Base (outflow tract)
    • ¤Subxiphoid
  49. ¨Subxiphoid may be best with ______________?
    increased anteroposterior chest dimensions (emphysema)
  50. S1 has two components, where are they heard best?
    • ¨The initial component is most prominent at the
    • cardiac apex when the apex is occupied by the left ventricle

    • ¨The second component, if present, is normally
    • confined to the lower left sternal edge, is less
    • commonly heard at the apex, and is seldom heard at the base
  51. What is the 1st component of S1 associated with?
    The first major component is associated with closure of the mitral valve and coincides with abrupt arrest of leaflet motion when the cusps, especially the larger and more mobile anterior mitral cusp, reach their fully closed positions
  52. What is the 2nd component of S2 associated with?
    The origin of the second component of S1 has been debated but is generally assigned to closure of the tricuspid valve based on an analogous line of reasoning
  53. What causes a loud S1
    • Short PR interval (<160 msec)
    • Tachycardia or hyperkinetic states
    • "Stiff" left ventricle
    • Mitral stenosis
    • Left atrial myxoma
    • Holosystolic mitral  valve prolapse
  54. What causes a soft S1
    • Long PR interval (>200 msec)
    • Depressed left ventricular contractility
    • Premature closure of mitral valve ( e.g., acute aortic regurgiation)
    • Left bundle branch block
    • Extracardiac factors (e.g., obesity, muscular chest, chronic obstructive pulmonary disease, large breasts)
    • Flail mitral leaflet
  55. Mid‐diastolic sounds are, for all practical purposes, either normal or abnormal ___ sounds
    S3
  56. Most, if not all, late diastolic or presystolic sounds are __ sounds
    S4
  57. When is S3 generated?
    during the rapid filling phase of the ventricle
  58. When is S3 normal?
    Frequent in normal children and in patients with high cardiac output
  59. When is S3 abnormal?
    • In older patients an S3 is abnormal
    • ¤Impairment of ventricular function
    • ¤AV valve regurgitation

    • Other conditions that increase the rate or
    • volume of ventricular filling
  60. What is the different between a L sided S3 and a R sided S3?
    • Left sided S3
    • ¤Bell piece of the stethoscope
    • ¤Left ventricular apex during expiration
    • ¤Left lateral position

    • Right‐sided S3 
    • ¤Left sternal border or just beneath the xiphoid
    • ¤Louder with inspiration
  61. Describe the 2nd and 3rd phases of ventricular filling (after the rapid filling phase)
    • Second filling phase‐diastasis
    • ¤Variable in duration
    • ¤Usually < 5 % of ventricular filling

    • Third phase of diastolic filling
    • ¤In response to atrial contraction
    • ¤15 % of normal ventricular filling
  62. When is S4 generated?
    S4 is generated during the atrial filling phase
  63. Describe the S4 and the situation in which it is found.
    • Low‐pitched, presystolic sound
    • ¤Associated with an effective atrial contraction
    • ¤Best heard with the bell piece of the stethoscope
    • ¤Loudest at apex
    • ¤Left lateral decubitus position

    • Diminished ventricular compliance
    • Frequently accompanied by visible and palpable presystolic distention of the left ventricle
  64. What are some cardiac conditions in which you would hear S4?
    • Systemic hypertension
    • Aortic stenosis
    • Hypertrophic cardiomyopathy
    • Ischemic heart disease
    • Acute mitral regurgitation
    • Most patients with an acute myocardial infarction and sinus rhythm have an audible S4
  65. What are you hearing when you auscultate a murmur?
    Turbulent blood flow
  66. How is the intensity (loudness) of a murmur graded?
    graded l‐Vl
  67. What characteristics (general categories) of the murmur do you define?
    • ¤Location and radiation
    • ¤Timing in cardiac cycle
    • ¤Configuation
    • ¤Pitch
  68. What is some basic information we can obtain from  an EKG?
    • ¨Heart rate and rhythm
    • ¨Chamber enlargement
    • ¨Prior infarction
    • ¨Ischemia
    • ¨Metabolic abnormalities
    • ¨Drug effects
    • ¨Risk for lethal arrhythmias (prolonged QT)
  69. what kind of information can we obtain by getting a CXR?
    • ¨Cardiac size
    • ¨Great vessels
    • ¨Pumonary vasculature
    • ¨Interstitial or alveolar edema
    • ¨Non cardiac causes of dyspnea
  70. What kind of information can we obtain my getting an ECHO?
    • ¨Chamber dimensions
    • ¨L & R ventricular function
    • ¨Valve structure
    • ¨Abnormal flow
    • ¤Valvular regurgitation or stenosis
    • ¤Intracardiac shunts
    • ¨Congenital lesions
    • ¨Pericardial disease
  71. What will stress testing show us?
    • ¨Exercise tolerance
    • ¨Coronary blood flow reserve
    • ¤Ischemic ECG changes
    • ¤Wall motion abnormality by echocardiography
    • ¤Perfusion defect with nuclear imaging
  72. What will a cardiac catheterization show us?
    • ¨Presence and degree of coronary artery disease
    • ¨Left ventricular systolic and diastolic function
    • ¨Presence and hemodynamic consequences of valvular disease
  73. What are the Pros of an exercise EKG
    • ¤Can assess functional capacity
    • ¤Safe and widely available
    • ¤Long history of data in varying populations
    • ¤No radiation exposure
  74. What are the Cons of an exercise EKG?
    • ¤Sensitivity lower than with imaging (70%)
    • ¤Specificity poor if abnormal baseline ECG
    • Doesn’t localize or quantify ischemia
  75. What are the pros of nuclear imaging?
    • ¤Good sensitivity and specificity (85%)
    • ¤Well validated studies to detect CAD and assess prognosis
    • ¤Can determine the extent and location of ischemia
  76. What are the Cons of nuclear imaging?
    • ¤Intermediate radiation exposure
    • ¤Time consuming
    • ¤$$$
    • ¤Inaccurate in the presence of left bundle branch block
  77. What are the pros of a stress ECHO?
    • ¤Good sensitivity and specificity
    • ¤Quick, readily available
    • ¤No radiation
    • ¤Less expensive than nuclear imaging
    • ¤Localization of ischemia
    • ¤“other” data
  78. What are the Cons of a stress ECHO?
    • ¤Obese or very thin may not image well
    • ¤Less accurate in setting of baseline abnormalities
    • ¤Interpretation is subjective and nonstandardized
  79. What are the pros of coronary calcium scoring?
    • ¤Readily available and inexpensive
    • ¤Not limited by conduction system abnormalities
    • ¤No need to exercise
    • ¤Non‐invasive
  80. What are the cons of coronary calcium scoring?
    • ¤No functional information
    • ¤Very low specificity, esp. in pts >60yo
    • ¤Radiation exposure
    • ¤No good reproducible data on outcomes
    • ¤Inappropriate utilization
  81. What are the Pros of CT angiography?
    • ¤Non‐invasive
    • ¤Very good at identifying native coronary disease
  82. What are the Cons of CT angiography?
    • ¤High radiation dose
    • ¤Inability to intervene
    • ¤No functional information, only anatomic
  83. What are the pros of a coronary angiogram?
    • ¤Direct visualization of the coronary lumen
    • ¤Good prospective therapeutic data based on
    • coronary angiographic results
    • ¤Ability to intervene
  84. What are the cons of a coronary angiogram?
    • ¤Does not assess functional significance of lesion
    • ¤Radiation exposure
    • ¤Invasive
  85. Limitation of All Stress Testing Modalities
    Inability to identify plaques that are vulnerable to rupture and thus development of acute coronary syndrome.
  86. What are some things we assess for intraop?
    • ¨EKG
    • ¨Hypotension
    • ¨Hypertension
  87. What area of ischemia/infarction will show in leads II, III & aVF?
    the inferior wall
  88. What area of ischemia/infarction will show in leads I, aVL, V4-V6?
    lateral wall
  89. What area of ischemia/infarction will show in leads V1-V3?
    anteroseptal
  90. What area of ischemia/infarction will show in leads V1-V6?
    anterolateral
  91. Patient-related complications associated with using NIBP devices
    • ¤Most common complication: skin & tissue  compression which can lead to skin irritation and bruising
    • ¤Prolonged use and frequent blood pressure determinations → venous pooling and congestion
    • ¤Excessive venous pressures →tissue ischemia and nerve damage.
  92. Factors that can interfere with obtaining accurate NIBP measurements
    ¤Highly irregular or rapid cardiac rhythms because of great beat to beat variability (most NIBP devices employ oscillometric technology that is dependent on fairly regular cardiac rhythms to determine blood pressure)

    ¤Excessive patient movement such as shivering, restlessness, or external movement such as that from a helicopter, ambulance transport, or a rapid-cycling ventilator can interfere with detection of cardiac oscillations by the NIBP monitor→ erroneous blood pressure measurements

    ¤Surgical team leaning on cuff!!*
  93. Causes of hypotension: Differential diagnosis (DDD  VITAMINS)
    • D Developmental (valvular heart disease)
    • D Drugs (Anesthetics & other drugs)
    • D Degenerative (Neurologic)
    • V Vascular (CV instability)
    • I Infectious/Iatrogenic (Adverse reactions, surgical)
    • T Toxic/Traumatic (Hemorrhage, sepsis)
    • A Autoimmune/Anoxic (Anoxic brain injury)
    • M Metabolic/Medical (Medical causes)
    • I Endocrine (Pregnancy)
    • N Neoplastic (Cancers)
    • S Special (Postoperative, deliberate)
  94. What are some causes of hypotension in the OR?
    • Hypovolemia…NPO!
    • Antihypertensive agents (ACEI and ARBs)
    • IV contrast agents
    • Methylmethacrylate…cement!!!
    • Allergens
    • Opioids
    • Antibiotics
    • Inhalational agents
    • Hypnotics
    • Regional anesthetics
    • --Epidural anesthesia
    • --Spinal anesthesia

    ¨
  95. What is deliberate hypotension and how do we achieve this
    Technique in general anesthesia in which a short-acting hypotensive agent is administered  to reduce blood pressure and thus bleeding during surgery. The procedure facilitates  surgery by making vessels and tissues more visible and reducing blood loss.

    • Sodium nitroprusside commonly used
    • ¤Afterload reducer w/ rapid onset &  short half-life
    • ¤Easy to titrate
    • ¤Disadvantages:

    • Can also use NTG & esmolol or Inhalational agents!!
    • In normal patients, perfusion preserved at MAP > 50mm Hg
  96. What are some causes of hypertension?
    • ¨Essential HTN
    • ¨Endocrine
    • ¨Renal
    • ¨Neurogenic
    • ¨Systolic HTN with wide pulse pressure (older people)
    • ¨Miscellaneous causes
  97. What are some examples of HTN related to pre-existing disease?
    • Preexisting HTN
    • Early acute MI
    • Aortic dissection
    • IICP
    • Autonomic hyperreflexia
  98. What are some examples of HTN related to surgery?
    • ¤Prolonged tourniquet time
    • ¤Aortic cross-clamping
    • ¤Postmyocardial revascularization
  99. What are some causes of HTN related to anesthesia?
    • ¤Pain/catecholamine release
    • ¤Inadequate depth of anesthesia
    • ¤Hypoxia
    • ¤Hypervolemia
    • ¤Hypercarbia
    • ¤MH
    • ¤Shivering
    • ¤Improperly sized BP cuff (too small)
    • ¤Transducer artifact-increased resonance
    • (improperly low position of transducer)
  100. Causes of HTN related to medication? What about other causes of HTN?
    • ¤Rebound HTN (if clonidine, BB, or
    • methyldopa d/c’d)
    • ¤Systemic absorption of vasoconstrictors
    • ¤IV indigo carmine dye

    • ¨Others
    • ¤Bladder distention
    • ¤Hypothermia & vasoconstriction
    • ¤Hypoglycemia
  101. What are frequent causes of HTN? 
    What are other causes to consider?
    What about rare causes?
    • Frequent, readily treatable causes:
    • ¤Pain, hypothermia with shivering, bladder
    • distention, essential HTN

    • Other causes to consider:
    • ¤Hypoxemia, hypercarbia, fever & its etiologies, anemia, hypoglycemia, tachydysrhythmias, withdrawal, myocardia ischemia, meds, PMH, surgical procedures, intraop events

    • Rare causes:
    • ¤Hyperthyroidism, pheochromocytoma, MH
  102. What are some major causes of post-op hypotension?
    • Spurious or incorrect readings
    • ¤Zero art line, size of BP cuff

    • Decreased SVR
    • ¤Regional anesthesia sympathectomy

    • Hypovolemia
    • ¤Unreplaced fluid deficit, unrecognized EBL, 3rd
    • spacing, ongoing fluid loss

    • Ventricular dysfunction
    • ¤Ischemia, impaired contractility, fluid overload, mobilization of fluid following regional anesthesia

    • Mechanical problems
    • ¤Tension pneumothorax or tamponade

    • Arrhythmias
    • ¤Preexisting heart disease, ischemia, decreased CO, meds
  103. Some causes of hypotension are that warming patient & controlling pain in PACU reduces sympathetic tone & redistributes blood volume to periphery. 
    Effects of surgical blood loss, 3rd spacing, ongoing hemorrhage, & inadequate volume replacement→hypotension. How do you treat???
    • ¨Must be treated swiftly & aggressively
    • ¨Volume expansion!!!!
    • ¨Then if necessary, vasopressors or inotropes
  104. What is the purpose of a cardiac evaluation?
    • ¨Determine preexisting cardiac disease
    • ¨Disease severity, stability, prior treatment
    • ¨Functional capacity
    • ¨Co-morbid conditions
    • ¨Type of surgery planned
  105. Name 4 active cardiac conditions
    • ¨Unstable Coronary Syndrome
    • ¨Decompensated Heart Failure
    • ¨Significant Arrhythmias
    • ¨Severe Valvular disease
  106. What are some clinical risk factors for cardiac disease?
    • ¨Known CAD
    • ¨Advanced age
    • ¨HTN
    • ¨Diabetes
    • ¨Hypercholesteremia
    • ¨Smoker
    • ¨Family History of premature CAD
  107. What four major questions are you going to ask regarding your patient with CAD?
    • ¨How much of myocardium is at risk?
    • ¨How much stress can myocardium handle before it becomes ischemic?
    • ¨What is patient’s LV function?
    • ¨Is the patient medically optimized?
  108. What is the definition of hypertension?
    • ¨Definition SBP >140 or DBP >90mmHg
    • ¨Stage 3 HTN
    • ¤SBP>180 mmHg
    • ¤DBP>110 mmHg
  109. Why should we optimize someone w/HTN?
    • ¤Reduces perioperative hemodynamic instability.
    • ¤Reduces instances of myocardial ischemia & CVA
  110. What you do you need to consider for your patient with AS?
    • ¤Symptomatic = delay or cancel
    • ¤Severe AS = Need study less than 12 months old
    • ¤What if patient is not a candidate or refuses AVR?---Don’t give a spinal!!!
  111. What is the definition criteria for aortic stenosis?
    • <1cm is severe
    • <0.6cm is critical
    • 1.5-1cm is moderate AS
  112. Tell me about severe Mitral stenosis
    ¤At increased risk for heart failure

    ¤Only surgically repair valve prior to non-cardiac surgery if there is a need that is not related to proposed surgery
  113. What do you need to do if someone is on an oral anticoagulant
    • ¤Superficial procedures?
    • --Normalize INR then restart post-op

    • ¤Otherwise?
    • --Heparin bridge to surgery
  114. What are the levels of evidence
    • Class I
    •   Benefit>>>Risk

    • Class IIa
    •   Benefit>>Risk

    • Class IIb
    •   Benefit> or = to Risk

    • Class 3
    •   Risk> or = to Benefit
  115. Why do we do pre-op testing?
    ¨Provide a framework to consider cardiac risk for non-cardiac surgery

    ¨Use this knowledge to individualize care
  116. Non-invasive eval of LV function (when would you do this?)
    ¨Class IIa: Patients with dyspnea of unknown origin,

    ¨Class IIa: Patients with current or prior heart failure. (if not been evaluated in past 12 months)

    ¨Class IIb: Reassessment of LV function in previously documented cardiomyopathy in  clinically stable patient is not well established.

    ¨Class III Routine perioperative evaluation of LV function is not recommended.
  117. Resting EKG (When would we do this?)
    •Class I: Patients with at least 1 clinical risk factor undergoing vascular procedures.  (diabetes, CHF, etc) *not for bunuectomy

    •Class I: Patients with known CAD, PVD, cerebrovascular disease undergoing intermediate risk surgical procedure  (thyroidectomy).

    •Class IIa: No risk factors but having vascular procedure (healthy person getting carotid surgery,  get EKG)

    • •Class IIb: Patients with at least 1 risk factor
    • having intermediate risk operation.
    • (HTN & thyroidectomy-get EKG?)

    • •Class III Pre-op and post-op resting 12
    • lead ECG is not indicated for asymptomatic patients having low risk surgery.
  118. Non invasive stress test (when would we do this?)
    •Class I: Active cardiac conditions in which non-cardiac surgery is planned should be evaluated and treated before surgery.

    •Class IIa: Patient’s with 3 or more clinical risk  factors and poor functional capacity who require vascular surgery.

    •Class IIb: May consider for patients with 1-2 clinical risk factors and poor functional capacity who require intermediate risk surgery.

    •Class IIb: May consider for patients with 1-2 clinical risk factors and good functional capacity having vascular surgery.

    •Class III: No clinical risk factors having intermediate risk or low risk surgery.
  119. Coronary Revascularization (CABG or PCI), who would be Class I for this?
    Class I: Patients with stable angina who have significant LM disease.

    Class I: Patients with stable angina who have 3 vessel disease.

    Class I: Patients with stable angina who have 2 vessel disease with significant proximal LAD  stenosis and EF less than 50% or demonstrable ischemia on non-invasive stress testing

    Class I: Patients with high risk unstable angina or non ST segment elevated MI.

    Class I: Patients with acute ST-elevation MI.
  120. Coronary revascularization (CABG or PCI), who would be class IIa for this?
    Class IIa: PCI to mitigate cardiac symptoms in patients who need elective surgery in next 12M.

    Class IIa: Patients who have received drug- eluting stents needing urgent surgery that mandate discontinuing thienopyridine therapy.
  121. Coronary revascularization (CABG or PCI), who would be class IIb?
    • Class IIb: Not well established for patients with
    • high risk ischemia or low risk ischemia. (dobutamine echo with 5 segements of wall motion abnormalities or 1 to 4 segements)
  122. Coronary revascularization (CABG or PCI) who would be Class III for this?
    Class III: Routine prophylactic revascularization is not recommended in patients with stable CAD.

    Class III: Elective surgery is not recommended for 4-6 weeks after bare metal stents, 12 months for drug eluting if dual antiplaelet therapy needs to be discontinued  perioperatively.

    Class III: Surgery is not recommended for 4 weeks after PTCA.
  123. Who is class I for Beta blocker therapy?
    ¨Class I: Continue beta blockers for those taking beta blockers for angina, symptomatic arrhythmia’s, HTN.

    ¨Class I: Give to patients undergoing vascular surgery who are at high cardiac risk according to preoperative testing.
  124. Who is Class IIa for betablocker therapy?
    Class IIa: Recommended for patients who pre-op assessment testing identifies CAD.

    • Class IIa: Probably recommended for patients
    • having vascular surgery with 1 clinical risk  factor. (HTN, taking diuretic for control)

    • Class IIa: Probably recommended for patients
    • identified as having CAD or high cardiac risk by the presence of 1 more than 1 clinical risk  factors.
  125. Who is class III for beta blocker therapy?
    Class III: Avoid use in those with absolute contraindications for beta blocker therapy.
  126. What are the different classes for Statin therapy?
    ¨Class I: If on a statin, continue.

    • ¨Class IIa: Reasonable use for those with or
    • without clinical risk factors having vascular surgery.

    • ¨Class IIb: Consider for those with at least 1
    • clinical risk factor having intermediate risk procedure.
  127. What are the different classes for Alpha 2 agonist?
    • ¨Class IIb: May consider for pre-op control of HTN
    • in those with CAD or at least 1 clinical risk factor.

    ¨Class III: Avoid in those patients with absolute contraindication for these medications.
  128. Who should be admitted to the ICU PRE-OP?! (What class?)
    • Class IIb:
    • ICU monitoring with Swan Ganz catheter in order to optimize hemodynamic status should be used only in highly select patients who are unstable and have multiple comorbid conditions
  129. Who can benefit from volatile anesthetic agents?
    Class IIb: Can be beneficial to maintain anesthesia in hemodynamically stable patients at risk for ischemia
  130. Who (what class) of patients need prophylatic intraop NTG?
    Class IIb: Unclear if intraop use for patients at high risk for myocardial ischemia is warrented
  131. What about intraop TEE, what class is that?
    Class IIb: Reasonable to use in emergent case to determne cause of acute persistent hemodynamic abnormality.
  132. What class is maintenance of body temperature
    Class I: Recommended for most procedures  other than in ones where hypothermia is intended to provide organ protection
  133. What are the classes for glycemic control?
    • Class IIa: Reasonable to control glucose in DM
    • patients and those at risk for myocardial ischemia having vascular and high risk surgery with planned ICU admission.

    Class IIb: Strict glucose control appears uncertain in DM patients or acute hyperglycemia patietns having surgery without planned ICU admission.
  134. What are the classes for pulmonary artery catheters?
    • Class IIb: May be reasonable in patients at risk
    • for hemodynamic disturbances easily detected by PA catheter.

    Class III: Routine use is not recommended
  135. What are the classes for ST segment monitoring?
    • Class IIa: Intra and post-op monitoring can be
    • useful in monitoring those with known CAD and those having vascular surgery.

    • Class IIb: May consider use in those with 1 or
    • multiple risk factors for CAD.
  136. What are the classes for surveillance for perioperative MI?
    Class I: Measure troponin on patients with ECG changes or with chest pain typical for acute  coronary syndromes.

    ¨Class IIb: Not well established for stable patients having had vascular or intermediate risk surgery.

    ¨Class III: Not recommended for asymptomatic patients having had low risk surgery

    • ¨Class IIb: Uncertain for patients with only 1
    • clinical risk factor having intermediate risk procedure or vascular procedure.

    • ¨Class IIb: Uncertain for those having vascular
    • surgery and not currently on beta blocker.
  137. What do we do if a patient has a pacemaker?
    • Evaluate pacemaker 3-6 months prior to surgery
    • Evaluate pacemaker after surgery
    • Set to asynchronous if pacer dependant or use magnet
    • ICD set tachyarrhythmia settings to off
  138. What does the QT interval represent?
    Duration of ventricular systole
  139. ___ limb leads form the frontal plane
    SIX
  140. ___ chest leads form the horizontal plane
    SIX
  141. What are the lateral leads?
    • •Lead I
    • •Lead AVL
  142. What are the lateral leads?
    • •Lead II
    • •Lead III
    • •Lead AVF
  143. What are the anterior chest leads?
    •V1

    •V2

    •V3

    •V4
  144. What are the RIGHT chest leads?
    •V1

    •V2
  145. What are the LEFT chest leads
    •V5

    •V6
  146. What are the septal leads?
    •V3

    •V4
  147. Name the 5 things we determine from an EKG
    • •1. Rate
    • •2. Rhythm
    • •3. Axis
    • •4. Hypertrophy
    • •5. Infarction
  148. Wolfe-Parkinson White Syndrome
    • •Abnormal accessory pathway, bundle of Kent
    • •Short circuits usual delay through AV node
    • •Delta wave on EKG, has illusion of shortened PR interval and lengthened QRS.
  149. What are the types of block?
    • •Sinus block
    • •Sick sinus syndrome
    • •Tachy-Brady syndrome
    • •1st degree AV block
    • •2nd degree AV block
    •    Wenckeback (formerly type 1)
    •    Mobitz (formerly type 2)
    • •3rd degree block
    •    Junctional focus
    •    Ventricular focus
  150. Describe a bundle branch block
    • •QRS is 0.12 seconds or greater
    • •Check V1 and V2 for RBBB
    •      R,R’ pattern
    • •Check V5 and V6 for LBBB
    •      R,R’ pattern
  151. Tell me about the axis
    • •Measure the Vector of electrical stimulus
    • •Follows the general direction of the  depolarization of the heart (uppper R to lower L)
    • •Mean RS vector
    • •Normal vector is downward and to the patient’s left
    • ----Between 0 degrees and +90 degrees is normal
    •       * 0 degrees is due left
    •       * +90 degrees is due south
  152. •Vector will point toward area of ___________

    •Vector will point away from area of _______
    • hypertrophy

    • Infarct
  153. For the axis, in Lead I and Lead aVF, both QRS are mainly positive, is this a normal axis?
    YES! (two thumbs up rule)
  154. For the axis, Lead I QRS is normally positive. If not then it's ________
    right axis deviation
  155. For the axis, Lead aVF QRS is normally positive. If not then it's _______
    left axis deviation
  156. For the axis, lead I and AVF both mainly negative then it's _________
    • •Then extreme right axis deviation
    • (# is extremely +)
  157. Tell me about axis rotation
    • •QRS normally begins more negative in V1 and becomes more positive in V6
    • •V3 and V4 are generally isoelectric
    • •QRS is about equal above and below
    • •Rightward rotation occurs when V1 or V2 are isoelectric
    • •Leftward rotation occurs when V5 or V6 are isoelectric
  158. Which lead (on a 12 lead EKG) do you check for atrial hypertrophy or enlargement?
    • •Check Lead V1
    • •Usually see a diphasic P wave
    •    -If initial component is larger then Right atrial enlargement
    •    -If terminal component is larger then Left atrial enlargement
  159. Where do you look for RV hypertrophy on an EKG?
    • •Lead V1
    •   - Large R wave, small S wave
    •   - R wave gets progressively smaller from V2-V6
    • •Also See
    •    - Right Axis Deviation
    •    -More vectors directed towards the  hypertrophied Right ventricle
    •   - Rightward rotation in horizontal plane
  160. Where do you look for LV hypertophy on an EKG?
    • Check V1
    • •Usually deep S wave but with LVH even deeper
    • •Also Left axis deviation and left rotation of vector
    • •V5 see Tall R wave
    • •So, measure depth of S wave in V1 and Height of R wave in V5
    •   (If total is greater than 35mm the LVH)
  161. Tell me about infarction and what you'll see on an EKG
    • •Ischemia
    • •Injury
    • •Necrosis
    • •Dead Tissue

    • •Q wave is diagnostic for infarction
    • •Significant Q waves are absent in normal EKG’s
    • •Tiny q waves are insignificant
    • •Q wave >.04 seconds or 1/3 of QRS
    • amplitude is significant
  162. In what leads would you see signs of anterior infarction?
    • •V1
    • •V2
    • •V3
    • •V4
  163. In what leads woould you see signs of inferior infarction?
    • •Lead II
    • •Lead III
    • •Lead AVF
  164. In what leads would you see signs of a lateral infarction?
    • •Lead I
    • •Lead AVL
  165. In what leads would you see signs of a posterior infarction?
    • •Lead V1
    • •Lead V2
    • •But….QRS is upside down relative to Anterior MI
  166. True or False. It can be difficult to see Q waves in LBBB.
    True!

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