RT 30 Final Exam Review. What is the blood flow through the heart? 1)Blood enters the heart thru the...

RT 30 Final Exam Review

What is the blood flow through the heart?

1) Blood enters the heart thru the inferior and superior vena cava

2) It then flows into the right atrium.

3) Thru the tricuspid valve into the Right Ventricle.

4) It then passes thru the pulmonic semilunar valve.

5) Then thru the pulmonary bed of the R. and L. lungs and back into the left atrium.

6) It then flows thru the bicuspid valve.

7) And into the left ventricle

8) Thru the aortic semilunar valve and into the aorta and systemic vascular system.

What is the normal conduction through the heart?

SA

AV

BH

PF

What is endocarditis? What can cause it?

An inflammation of the inner layer of the heart, It usually involves the heart valves

Other structures that may be involved include the interventricular septum, the chordae tendineae. Endocarditis is characterized by a prototypic lesion, the vegetation, which is a mass of platelets, fibrin, microcolonies of microorganisms, and scant inflammatory cells

Injection of bacteria through dirty needles

What is Pericarditis?

•Fluid accumulation surrounding the heart, may lead to a life threatening condition called cardiac tamponade

•Cardiac tamponade is compression of the heart that occurs when blood or fluid builds up in the space between the myocardium and the pericardium

What is Myocarditis? Myocarditis is most often due to infection by common viruses, less commonly nonviral pathogens such as Borrelia burgdorferi (Lyme disease) or Trypanosoma cruzi, or as a hypersensitivity response to drugs.

The definition of myocarditis varies, but the central feature is an infection of the heart, with an inflammatory infiltrate, and damage to the heart muscle, without the blockage of coronary arteries that define a heart attack (myocardial infarction)

What is Valvular disease?

Valvular heart disease is characterized by damage to or a defect in one of the four heart valves: the mitral, aortic, tricuspid or pulmonary.

The mitral and aortic valves are the ones most frequently affected by valvular heart disease.

Valvular heart disease is characterized by damage to or a defect in one of the four heart valves: the mitral, aortic, tricuspid or pulmonary.

The mitral and aortic valves are the ones most frequently affected by valvular heart disease.

Describe the following

CHF- CAD- MI- Cor Pulmonale- HTN-Pulm HTN- What are characteristics and treatments of each?

What are the names of the coronary arteries?

Left Coronary artery

Anterior Descending Artery

◦ Supplies anterior sulcus and apex

◦ Widow maker heart attack

Circumflex Artery

◦ Supplies posterior side of left ventricle

What are the names of the coronary arteries?

Together supply most of left ventricle, left atrium, 2/3 of intra ventricular septum, half of intra atrial septum, and part of right atrium

Supplies anterior and posterior portions of

right ventricular myocardium, right atrium,

sinus node, posterior 1/3 of intraventricular

septum, and portion of base of right ventricle

Right Coronary ArteryPosterior Descending Artery

◦ Supplies posterior intraventricular sulcus

Has numerous smaller branches

Coronary Veins

Closely parallel the arterial system

oSome coronary venous blood enters the heart through the Thebesian

veins

◦ Thebesian veins empty directly into all chambers thus creating some

venous admixture lowering Pa02

What is a MI? What causes it, how is it treated?

MONAMONA•Immediate assessment (<10 minutes)•Measure vital signs (automatic/standard BP cuff)

•Measure oxygen saturation•Obtain IV access•Obtain 12-lead ECG (physician reviews)•Perform brief, targeted history and physical exam;focus on eligibility for fibrinolytic therapy

•Obtain initial serum cardiac marker levels

•Evaluate initial electrolyte and coagulation studies

•Request, review portable chest x-ray (<30 minutes)

•Immediate general treatment•Oxygen at 4 L/min•Aspirin 160 to 325 mg•Nitroglycerin SL or spray•Morphine IV (if pain not relieved with

SVR and PVR formula

The Vascular System-Systemic The Vascular System-Systemic Vascular Resistance (SVR)Vascular Resistance (SVR)

Sum of all frictional forces opposing blood flow through the vascular circulation

SVR = Mean Aortic Pressure-Right Atrial Pressure x80 Cardiac Output

◦ Mean Aortic Pressure - Use Systolic Pressure (normal mean = 90mmhg)

◦ Right Atrial Pressure - Use Central Venous Pressure (normal mean = 4mmhg)

◦ Cardiac Output normal mean = 5L/min

PVR Formula:PVR Formula:

MPAP – PCWP / CO x 80

The Vascular System-Blood The Vascular System-Blood PressurePressure

Systolic Pressure

◦ Pressure during contraction phase of heart

◦ Normal value: 90 – 140 mmHg

Diastolic Pressure

◦ Pressure during relaxation phase of heart

◦ Normal value: 60 – 90 mmHg

http://www.nlm.nih.gov/medlineplus/ency/anatomyvideos/000013.htm

Mean Arterial Pressure

MAP = (2 x diastolic pressure) + (systolic pressure) 3

A MAP of about 60 is necessary to perfuse coronary arteries, brain, kidneys.

Cardiac Output Cardiac Index

◦ Volume of blood pumped by the heart per minute divided by body

surface area

CI = CO BSA

◦ Normal range of cardiac index is 2.5 - 4.0 L/min per square meter.Low values can indicate cardiogenic shock

Stroke Volume

End-Diastolic Volume (EDV)

Volume to which the ventricles fill during diastole

Formula: SV = EDV – ESV

Normal value: 60 – 130 ml/beat

Stroke Volume Ejection Fraction (EF)

◦ Proportion of EDV ejected on each stroke

EF = SV EDV

◦ Normal Value – 70%

Factors Affecting Stroke Volume

Preload

◦ Initial stretch of the ventricle

◦ The greater the preload, the greater the tension on contraction


Afterload

◦ Force against which the heart must pump

◦ In clinical practice, left ventricular afterload equals systemic vascular

resistance.


Contractility

◦ Amount of systolic force exerted by heart muscle at any given preload.

◦ Increases in contractility leads to higher EF, lower end systolic volume, and higher stroke

volume

Inotropic (drugs that increase cardiac contraction)

Chronotropic (drugs that increase cardiac rate)


Contractility

◦ Decreases in contractility lead to

lower ejection fraction, higher end

systolic volume, and decreased

stroke volume.

Inotropism: Is any factor which affects

the contractility of the heart

◦ Positive Inotropism

◦ Higher stroke volumes for a given

preload: indicating an increase in

contractility.


Contractility

Negative inotropism

Decreased stroke volumes for a given preload:

indicates a decrease in contractility


Heart Rate (60-100)

Autonomic Nervous System

oSympathetic: fight or flight: HR, RR, BP, pupilary dilation

and bronchodilation.

oParasympathetic: rest and digest


Heart Rate

◦ Cardiac output directly proportional to heart rate

◦ Relationship exists up to 160 to 180 beats/min

◦ Filling time for ventricles insufficient at higher rates

Arrhythmia Review

Initial Approach—Analysis4 Questions

Rate?◦ Normal◦ Bradycardia, Tachycardia

Rhythm?◦ Regular or Irregular

Are there P waves?◦ Is each P wave related to a QRS with 1:1 impulse conduction?

QRS normal or wide?

34

Premature Atrial Contraction (PAC)

Sinus rateSinus rate

Irregular—interrupted by PACIrregular—interrupted by PAC

Incomplete compensatory pauseIncomplete compensatory pause

Different morphologyDifferent morphology

Usually conducted with normal QRSUsually conducted with normal QRS

Treat underlying causeTreat underlying cause

• RateRate• RhythmRhythm

• P wavesP waves• P → QRSP → QRS• TherapyTherapy

QRS Normal

35

Atrial Fibrillation

Atrial rate cannot be measuredAtrial rate cannot be measured

Ventricular rate—variableVentricular rate—variable

Irregular (irregularly irregular)Irregular (irregularly irregular)

Absent (fibrillation waves)Absent (fibrillation waves)

Conduction irregularConduction irregular

Slow ventricular rateSlow ventricular rate



• P wavesP waves• F → QRSF → QRS• TherapyTherapy

36

Atrial Flutter

Atrial rate 250-400/min (often 300)Atrial rate 250-400/min (often 300)

Ventricular rate—variableVentricular rate—variable

Regular (2:1 AV block common)Regular (2:1 AV block common)

Absent (flutter waves)Absent (flutter waves)

Conduction regular (unless variable block)Conduction regular (unless variable block)

Slow ventricular rate: terminate arrhythmiaSlow ventricular rate: terminate arrhythmia



• P wavesP waves• F → QRSF → QRS• TherapyTherapy

QRS Normal

Self-AssessmentWhat are the rate and rhythm?

37

B

A

38

Clinical Correlation

This patient is unresponsive and This patient is unresponsive and BP is 70/50 mm Hg.BP is 70/50 mm Hg.

What is the rhythm?What is the rhythm?

What is your next action?What is your next action?

39

PVC Morphology—Match the Name

• Unifocal PVCs

• Multifocal PVCs

• Bigeminy

• Ventricular Tachycardia

• Torsades

Ventricular Fibrillation (VF)

Polymorphic VT TX without pulse:

◦ CPR◦ DEFIB◦ EPI/Mg 2g

Ventricular TachycardiaMonomorphic*

Atrial rate normal Atrial rate normal

Onset tachycardia abruptOnset tachycardia abrupt

RegularRegular

Present—obscuredPresent—obscured

Blocked—fusion complexes possibleBlocked—fusion complexes possible

Antiarrhythmic agent, cardioversion, Antiarrhythmic agent, cardioversion,

high-energy (defibrillation dose) shock high-energy (defibrillation dose) shock



*Sustained—requires intervention for >30 seconds*Sustained—requires intervention for >30 seconds

Polymorphic VT*

Atrial rate normal (obscured)Atrial rate normal (obscured)

Onset tachycardia abruptOnset tachycardia abrupt

IrregularIrregular

Present—obscuredPresent—obscured

Blocked—fusion complexes possibleBlocked—fusion complexes possible

Unsynchronized high-energy shock,Unsynchronized high-energy shock,magnesium (beneficial with baseline QTmagnesium (beneficial with baseline QTCC

prolongation)prolongation)



*Torsades de pointes—QT prolonged*Torsades de pointes—QT prolonged

Ventricular Fibrillation

Chaotic, uncountable Chaotic, uncountable

Onset abruptOnset abrupt

IrregularIrregular

Absent; no normal QRS complexesAbsent; no normal QRS complexes

Not applicableNot applicable

Immediate shock(s) Immediate shock(s)



Coarse VF

Ventricular Fibrillation

Chaotic, uncountable Chaotic, uncountable

Onset abruptOnset abrupt

IrregularIrregular

Absent; no normal QRS complexesAbsent; no normal QRS complexes


Immediate shock(s) Immediate shock(s)



Fine VF

Asystole

Absent Absent

None—“flatline”None—“flatline”

AbsentAbsent


CPR, vasopressor CPR, vasopressor

• RateRate• RhythmRhythm• P wavesP waves• P → QRSP → QRS• TherapyTherapy

Agonal ComplexesPulseless Electrical

Activity

ASYSTOLE

Pulseless Electrical Activity (PEA)

Variable—depends on baseline rhythm Variable—depends on baseline rhythm

PEA is not a single rhythm but anyPEA is not a single rhythm but any

organized rhythm without a pulseorganized rhythm without a pulse

Identify and treat underlying causeIdentify and treat underlying cause

CPR, vasopressorCPR, vasopressor


• TherapyTherapy

ARTERIAL PRESSURE

A

B

A B

C

Self-AssessmentWhat are the rate and rhythm?

What rhythms do we defibrillate? Cardiovert?

1.

2.

Epinephrine • Epinephrine is a naturally occurring catecholamine with both - and - adrenergic agonist activity

• Administer 1 mg (10 mL 1:10 000 IV bolus) every 3 to 5 minutes during cardiac arrest

• Stimulation of -adrenergic receptors increases peripheral vasoconstriction and as a result increases coronary and cerebral blood flow

Epinephrine Stimulation of -adrenergic receptors

• Increases heart rate, contractility, and conduction velocity

• Increases conduction through the atrioventricular node

• Decreases the ventricular muscle refractory period: these latter effects may increase the likelihood of arrhythmias

Epinephrinein Cardiac Arrest

Epinephrine may be administered IV/IO

Endotracheal administration provides uncertain doses

Remember to flush with 20 mL of fluid and elevate the arm or leg

Important to REMEMBER:

High doses can cause arrhythmias

High doses do not improve survival and may contribute to postresuscitation myocardial dysfunction

Special ConsiderationsCautions—ContraindicationsSpecial ConsiderationsCautions—Contraindications

Vasopressin

• A naturally occurring hormone, also known as antidiuretic hormone (ADH)

• Causes vasoconstriction by directly stimulating smooth muscle receptors

• Causes no increase in myocardial oxygen consumption during CPR— no -receptor activity

Clinical studies have shown vasopressin Clinical studies have shown vasopressin equivalent to epinephrine for treatment of cardiac arrestequivalent to epinephrine for treatment of cardiac arrestClinical studies have shown vasopressin Clinical studies have shown vasopressin equivalent to epinephrine for treatment of cardiac arrestequivalent to epinephrine for treatment of cardiac arrest

Vasopressin can be substituted for the first or second dose of epinephrine

Give 40 units IV/IO bolus

Coronary perfusion pressure

Vital organ blood flow

Median frequency VF

Cerebral oxygen delivery

Vasopressin

Bradycardia

First-Degree AV Block

57

AV NodalAV NodalTissueTissue

AV NodeAV Node

His-Purkinje SystemHis-Purkinje System

PP

QRS <0.12QRS <0.12

>0.20 seconds>0.20 seconds

Sinus NodeSinus Node

• Underlying sinus rhythmUnderlying sinus rhythm

• One P wave One P wave

• PR interval >0.20PR interval >0.20secondsecond

• One P wave for each One P wave for each QRSQRS

Second-Degree AV Block—Mobitz IWenckebach Phenomenon

58


• P wave fails to P wave fails to periodicallyperiodicallyconduct conduct

• PR interval prolongedPR interval prolonged

• One P wave for each One P wave for each QRS until blockQRS until block

PR intervalPR interval



>0.20 seconds>0.20 seconds


QRSQRS

XX

PP

Second-Degree AV Block—Mobitz II

59


• One P wave One P wave

• PR interval usually PR interval usually normal, no prolongationnormal, no prolongation

• One P wave for each QRS One P wave for each QRS until sudden block and until sudden block and dropped QRSdropped QRS

PR intervals unchanged


AV NodeAV Node


PP

Often Often normal normal QRS QRS complexcomplex

Often NormalOften Normal


BlockBlock

60

Third-Degree AV Block—Junctional Escape

• Underlying sinus rhythm Underlying sinus rhythm (usual)(usual)

• Escape junctional rate 40-60 Escape junctional rate 40-60

• PR interval variablePR interval variable

• P waves unrelated to QRSP waves unrelated to QRS

• Narrow QRS = block above Narrow QRS = block above His junctionHis junction

AV NodeAV Node

His Purkinje SystemHis Purkinje System

PP

QRS <0.12QRS <0.12


QRS fromQRS fromAV-HisAV-His escapeescape

P waves unrelated to QRS

AV Block—Which Type?

Excitability

◦ Ability to respond to electrical, chemical, or mechanical stimulation

Properties of Heart Muscle

Excitability

This is important as the heart will respond to defibrillation, cardioversion, and

medication


Automaticity

◦ Ability of cardiac muscle to initiate a spontaneous electrical impulse (only cell capable

of doing this)

◦ Highly developed in specialized areas – pacemaker or nodal tissue


Automaticity of the heart is produced by spontaneous and repetitive depolarization of certain cardiac cells, known as pacemaker cells.

The depolarization of these cells leads to the generation of action potentials, which are electrical signals that are propagated throughout the cardiac muscle tissue and result in contractions. Understanding depolarization is essential to comprehending cardiac electrophysiology as a whole.

Automaticity

Depolarization: The process of depolarization occurs at the cellular level and involves changes in the electrical environment of a cell. This electrical environment is determined by the difference in the concentrations of charged particles between the inside and outside of the cell.

Automaticity

Resting Membrane Potential:

At rest, the inside of a myocardial cell has a charge that is more negative than its surroundings. Therefore, the cell is said to have a negative resting membrane potential. This potential is normally around -90 millivolts, meaning the charge inside the cell is 90 millivolts lower than the surrounding environment.

Automaticity

Conductivity

◦ Ability to radiate electrical impulses

◦ Impaired in response to necrotic tissue from ischemic

injury (MI)

Contractility ◦ Ability to contract in response to an electrical impulse

◦ Impaired by hypertrophy, cardiomyapathy, CHF


Activation of

Central Chemoreceptorsby changes in arterial Pco2

Chemoreceptors

IN

Medulla

CSF

BBB

plasma

capillary

CO2

CO2

H2OH2CO3

HCO3-

H+

Performing an EKG

Polarization

◦ Difference in electrical potential between two points in

tissue; the resting state of cardiac muscle

Basic Electrocardiography-Terms

Peripheral and central chemoreceptors respond to changes in blood chemistry, mainly CO2, pH and O2.

Low O2 = increase HR and RR High CO2 (H+ in medulla) = Increased HR and RRLow pH (aciditc) = Increase HR and RR

Baroreceptors: Increase pressure = Increased HR, decreased pressure = increased HR And contractility

Basic Electrocardiography

Depolarization

◦ Influx of sodium into the interior portion of the cells

causing muscle contraction

Repolarization

◦ Rapid return of the cell to the polarized state

Basic Electrocardiography-Terms

EKG Paper

P Wave

◦ Produced by atrial depolarization

◦ Normally 0.06 to 0.11 seconds in duration

The Electrocardiogram

QRS Complex◦ Produced by ventricular depolarization◦ Normally 0.03 to 0.12 seconds in duration◦ Repolarization of the atria occurs

simultaneously with QRS and is hidden by the QRS complex


T Wave

◦ Produced by ventricular repolarization

◦ Normally 0.14 to 0.26 seconds


PR Interval◦ Time from beginning of atrial depolarization to beginning of

ventricular depolarization◦ Normal interval is 0.12 to 0.20 seconds


RR Interval◦ Time from peak of one QRS complex to the next QRS

complex◦ Normally 0.6 to 1.0 seconds◦ Used to measure total cardiac cycle


PP Interval

◦ Time from beginning of one P wave to the beginning of the next P

wave

◦ Normally equal to RR interval

◦ Also used to measure total cardiac cycle


Lead I: ◦ (-) Negative Electrode on Right Arm ◦ (+) Positive Electrode on Left Arm

ECG Leads

Rate less than 60

Rhythm is regular

P wave prior to each QRS/QRS for each P wave

PR interval normal

QRS interval normal

Sinus Bradycardia

Rate greater than 100

Rhythm is regular


PR interval normal

QRS interval normal

Sinus Tachycardia

Causes

• Fever• Anxiety• Pain• Dehydration• Anemia• Hypoxemia (generally first sign)

If symptomatic:• Anxiety• Feelings of fear or panic• Feelings of a pounding chest• Treat underlying cause• http://www.youtube.com/watch?v=cKXrzLrQOCc

Sinus Tachycardia

Rate 100-160 BPM

Rhythm is irregular

P waves absent and replaced by irregular electrical activity

QRS interval normal to narrow

Most common arrhythmia

Atrial Fibrillation

Causes:◦ Disorganized electrical impulses that originate in the atria and pulmonary veins◦ Hypertension◦ Hyperthyroidism◦ Primary heart disease

If symptomatic:PalpitationsSOBExercise intoleranceClot formation within heart/lungs/brain/legs Ect.Dizziness/ somnolence/ decreased LOChttp://www.youtube.com/watch?v=70QE1poMZ1E&feature=related

Atrial Fibrillation

Treatment• Anti-Coagulants• Beta Blockers

If symptomatic:• Immediate Cardioversion• Oxygen

http://www.youtube.com/watch?v=1rcg6Ce7p18

Atrial Fibrillation

Lead II

◦ Negative Electrode on Right Arm, Positive Electrode on Left Leg

◦ Used Most Commonly in Acutely Ill Patients With Leads Placed on Chest

Rather Than on Limbs

ECG Leads

Lead III

◦ Negative Electrode on Left Arm, Positive Electrode on Left Leg

Leads I, II, and III Comprise Einthoven’s Triangle And Present Electrical

Activity of The Heart From Three Different Orientations

ECG Leads

03 Sept. 2013 EKG-Lab.ppt92

Electrocardiogram

Einthoven’s triangle• Three standard limb leads

• Voltage differences between corners of triangle

• We will use “Lead II”◦ Right shoulder to left leg

Limb Leads

Precordial Leads

◦ Leads V1, V2, V3, V4, V5, And V6

◦ V1 – Positive Electrode Placed at Right Sternal Margin And

Fourth Intercostals space

ECG Leads

Precordial Leads

◦ Successive Leads Placed Laterally to The Left With V6 at Mid

Axillary Line

◦ Electrical Activity Measured From Six Different Locations And

Depicted Differently For Each Lead

ECG Leads

Precordial Leads

Rate less than 60

Rhythm is regular


PR interval normal

QRS interval normal

Sinus Bradycardia

Rate greater than 100

Rhythm is regular


PR interval normal

QRS interval normal

Sinus Tachycardia

Sinus Tachycardia Causes

• Fever• Anxiety• Pain• Dehydration• Anemia• Hypoxemia (generally first sign)

If symptomatic:• Anxiety• Feelings of fear or panic• Feelings of a pounding chest• Treat underlying cause

http://www.youtube.com/watch?v=cKXrzLrQOCc

Rate 100-160 BPM

Rhythm is irregular

P waves absent and replaced by irregular electrical activity

QRS interval normal to narrow

Most common arrhythmia

Atrial Fibrillation

Causes:◦ Disorganized electrical impulses that originate in the atria and pulmonary veins◦ Hypertension◦ Hyperthyroidism◦ Primary heart disease

If symptomatic:PalpitationsSOBExercise intoleranceClot formation within heart/lungs/brain/legs Ect.Dizziness/ somnolence/ decreased LOC

http://www.youtube.com/watch?v=70QE1poMZ1E&feature=related

Atrial Fibrillation

Treatment• Anti-Coagulants• Beta Blockers

If symptomatic:• Immediate Cardioversion• Oxygen

http://www.youtube.com/watch?v=1rcg6Ce7p18

Atrial Fibrillation

Rate 140-220

Rhythm is regular

P waves absent (buried in the T wave)

QRS interval usually normal

PR interval - impulses stimulating the heart are not being generated by the sinus node, but instead are coming from a collection of tissue around and involving the atrioventricular (AV) node

Supraventricular Tachycardia

•Causes:CADThyroid diseaseCOPDCaffeineStress

• If symptomatic: Palpitations Dizziness Anxiety Chest pain Loss of consciousness

http://www.youtube.com/watch?v=ReJo4aclOw8


Treatment Vagal manuvers Carotid massage Cardioversion: Electrical/Chemical (Adenosine) Medications Oxygen Ablation Pacemakerhttp://www.youtube.com/watch?v=xLzRFAT9uFA


NSR-o Is the rate regular? o Is the rate between 60-100?o Is their a P wave prior to each QRS/ QRS for each P wave?o Is the PR interval normal - .12 to .2 Sec? (less than 1 big box)o Is the QRS interval less than .12 Sec? (less than 3 little boxes)

Basic ECG Interpretation

PHARMACOLOGY (indications/dose and classification)

Adenosine

Atropine

Amiodarone

Lidocaine

Epinephrine

Dopamine

Levophed

Vasopressin

Depolarizing Agents

Bind to acetylcholine receptor sites causing a post-synaptic membrane depolarization

Prevention of repolarization causes the post-synaptic ending to become refractory and unexcitable, resulting in muscle flaccidity

ActionPrevents acetylcholine from binding at the receptor siteShorter acting than non-depolarizing agentsWill cause total muscle paralysis in 60 to 90 seconds that lasts from 10 to 15 minutesDo not have reversing agents

Generic name Proprietary name

Succinylcholine Anectine

Indications- Short acting paralytic ideal for intubation or

similar procedures

Non-Depolarizing Agents

Produce paralysis and muscle weakness by competing with acetylcholine for binding at the receptor sitePrevention of the binding of acetylcholine prevents depolarization of the site, thereby preventing muscle contraction

Action

Competitive inhibition of acetylcholine at muscle post-synaptic receptor site Effects felt in 2 to 10 minutes and last for 30 to 60

minutes May be reversed by cholinesterase inhibitors, e.g.,

Neostigmine

Generic Name Proprietary NameTubocurarine d-tubocurarine

Pancuronium PavulonMetocurine Metubine

Vecuronium NorcuronRocuronium Zemuron, Esmeron

Indications- Need for longer term paralysis- Patient-ventilator synchrony- Muscle relaxation during surgery

- Indications- Reduction of intracranial pressure- Immobility in trauma patients-- Minimize oxygen consumption

Indications for NMBAs

Endotracheal intubation

Muscle relaxation during surgery

Enhancement of patient-ventilator synchrony

Reduction of intracranial pressure in intubated patients

Minimizes oxygen consumption

Facilitation of procedures or diagnostic studies

Maintenance of immobility, e.g., trauma patients (Flail Chest)

Narcotis and Analgesics Know opiods (high, mod, low potency)

Morphine

Oxymorphone

Fentanyl

Methadone

Hydromorphone (Dilaudid)

Demerol

Percocet

Oxycontin

Codeine

Narcotic Antagonist Narcan

Sedative and Hypnotics Ativan

Versed

Xananax

Valium

Deprivan

Haldol

Pentothal

Pentobarbital

Phenobarbital

Reversal of Benzos Ramazicon

Other Meds Diruretics: Diamox, Lassix, Mannitol, Carbonic anyhydrase inhibitors

Steroids: Side effects, indications…

HEMODYNAMICSValues PAP, CVP, PCWPCauses of each to increase/decreaseIndications for PICC, A-lines, Central and PA linesTroubleshooting PA and A-line tracingsCardiac output assessments

Formulas CVO2=

DO2=

C(a-v)=

SVO2=

EF=

PFT’S

Spirogram

Lung Volumes & Capacities

Examples of Flow-Volume Loops in Disease States

SVCPurpose:

To determine the maximum amount of the volume that can be taken in and exhaled with a single breath

FVCTo measure flow rates and lung volumes in order to determine the presence of obstructed or restricted lung impairment

Spirometry

Forced vital capacity (FVC)

◦ Technique – subject breaths normally for several breaths, then inspires

maximally and exhales as forcefully and fully as possible

◦ Should be within 200 mL of VC

Spirometry

Forced expiratory volume (most commonly FEV1)

◦ Volume which can be exhaled in one second using maximum patient effort

◦ Determined from the FVC

◦ Decrease in value indicates obstructive changes in small airways

Spirometry

Spirometry

FEF25%-75%

◦ Average expiratory flow rate of the middle 50% of the FVC

◦ Measured in liters per second

◦ Indicates flow from medium and small airways

◦ Changes from smoking occur in medium airways prior to changes in small airways

MVV To measure muscle strength during times of increased exertion

Measurements of RV/TLC Nitrogen Washout Helium Dilution Body Box

Spirometry

Maximum voluntary ventilation (MVV)

◦ Calculates the maximum volume of gas that a patient can ventilate in one minute

◦ Technique – subject is directed to breathe rapidly and deeply for 12 to 15 seconds;

the total volume inspired or expired is measured; the volume is extrapolated to one

minute

DLCO To evaluate the ability of the lungs to take in oxygen from the air, and transfer the oxygen across the lungs into the blood stream

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Interpreting the PFT Report The FEV1/FVC ratio is a good place to start; reduced (<70%) with obstructive lung disease

If TLC less than 80% of predicted normal and FEV1/FVC is normal, restrictive disease is present.

If DLCO is <80% of normal, a diffusion defect is present.◦ Reduced surface area = emphysema◦ Thickened AC membrane = pulmonary fibrosis

RT 30 Final Exam Review. What is the blood flow through the heart? 1)Blood enters the heart thru the...

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