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81 Cards in this Set
- Front
- Back
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Cardiogenic Shock is... |
Sustained BP <90 mmHg despite therapy |
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What is hemodynamic balance and compensation? |
Balancing supply vs. demand between sympathetic and parasympathetic nervous systems |
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What is the goal of compensation? |
maintain perfusion |
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Methods of cardiac compensation. |
HR increases Contractility increases After load changes (myocardial, systemic & pulmonary) |
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What can happen that may nullify the ability to compensate? |
Valve disorders CAD/ MI Cardiomyopathy ECG changes (arrhythmias) Anemia |
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What is C.R.A.P.? |
Contractility Rate Afterload Preload |
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Questions to ask yourself for treating symptomatic patients. |
acute or chronic presentation? diseased or normal heart? how is oxygen supply & demand affected? know your C.R.A.P. |
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How is preload measured in the cath lab? |
End-diastolic ventricular volume |
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How does Frank-Starling law influence EDV (increased preload) and cardiac perfusion? |
With increased volume there is increased contractility up to a point then unable to increase so dilates |
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How does increased preload affect cardiac workload? |
Increased preload = increased contractility = increased oxygen consumption of the heart (cardiac workload) |
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What events result in decreased contractility? |
Loss of atrial kick (A Fib/ Vent. arrhythmias) Increased preload due to valve problems, HF, etc... Ischemic events Medications |
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What events result in increased contractility? |
Compensation by CNS Medications (digoxin) Increased preload Exercise |
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Can afterload be directly measured? |
No, only calcuated using formulas |
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What is afterload? |
Contraction of arterioles |
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Normal SVR range? |
770-1500 dynes/sec 9.6-18.75 HRUs |
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Normal PVR range? |
20-120 dynes/sec 0.25-1.5 HRUs |
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How does afterload affect the function of the heart? |
Shunts blood back toward vital organs. (SVR) Increases myocardial workload & oxygen consumption. |
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Systemic after load is... |
Regulation of blood flow through body to meet demand imposed on the heart |
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Pulmonary after load is... |
Normally very low due to high degree of vascular distension in the lungs |
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Coronary after load is... |
Greatly affected by the presence of CAD |
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Which law governs after load? |
Poiseuille's Law |
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According to Poiseuille's Law, what vessel changes affect resistance the most? |
Changes in radius because Resistance is inversely proportional to the arterial radius to 4th power. |
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Formula for calculating SVR? |
SVR = (MAP - RA mean)/CO * 80 |
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Formula for calculating PVR? |
PVR = (MPA-PCW mean)/CO * 80 |
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What is angiographic formula for CO? |
CO = SV * HR |
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What is vital to maintaining or improving the failing heart? |
Improving CO |
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IABP flow rates |
0.5 L/min. in Left Heart only May be used for days not longer |
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Impella flow rates |
2.5 L/min or 5.0 L/min in Left Heart only May be used for weeks |
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Tandem Heart flow rates |
5.0 to 8.0 L/min in Left OR Right heart May be used for months. |
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Main goal of IABP Therapy? |
Increase perfusion while decreasing workload |
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Effects of IABP Therapy include... |
Increased CO, O2 supply & collateral flow. Decreased preload and after load status. Increased coronary, cerebral & renal flow by providing perfusion during diastole. Decreased AO pressure during systole. Reduced myocardial demand & O2 consumption. Reduced PCW and central venous pressures Decreased pulmonary congestion. |
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Indications for IABP? |
Unstable angina Scute MI Cardiogenic shock Cardiac contusion Poor LV function Prophylaxis to high risk procedure Post CABG assist Bridge to transplant |
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Contraindications to IABP? |
AO dissection Excessive AO or illiac artery tortuosity Severe AO disease Severe illiac artery disease AI |
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Complications of IABP? |
Access site complications (femoral) Clots/ distal embolization Renal artery occlusion Left Subclavian occlusion (left vertebral & internal mammory)
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General sizing rules for IABP |
25 cc = pediatric 34 cc = 5'4" 40 cc = 5'4" to 6'0" 50 cc = 6'0" up |
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Things to check to ensure IABP is above renal arteries and below left subclavian... |
Urine production Radial pulse in left wrist (two pulses) |
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How is IABP inflation triggered? |
Senses QRS |
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What rhythms is IABP good at sensing? |
Regular & normal Single or dual chamber paced (sense pacer spike) |
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IABP inflates during this part of Wiggers |
After AO valve closes (diastole) |
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IABP deflates during this part of Wiggers |
Before MV closes (before systole) |
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Effect of IABP when inflated? |
Perfuses heart, head, systemic No effect on O2 demand since heart in diastole |
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Effect of IABP when deflated? |
Sudden decrease in volume taken up by IABP results in decrease in AO pressure. Allows blood to flow around in cardiac systole. |
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Correct IABP timing? |
1 augmented for every 2 intrinsic beats |
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Effect of early IABP inflation? |
Forces AO valve to close prematurely increasing after load, AO pressure, O2 consumption, impaired ventricular filling (decreased SV, increased preload, increased PCW) |
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Effect of late IABP deflation? |
Impaired ventricular ejection (decreased SV, decreased EF & ejection velocity), O2 consumption |
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Indications for Impella? |
High risk PCI Low EF Acute hemodynamic instability Only 1 coronary artery open (last open conduit), STEMI Acute MI Cardiogenic shock |
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Contraindications for Impella? |
Severe PAD (can't get access in FA) Mechanical AO valve LV thrombus. Severe AS, calcification, or thrombus Severe AI (2+ or more) |
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How does Tandem Heart work? |
Takes blood from LA and delivers it to Femoral Artery (FA) for circulation. |
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Recommended bed position post-removal of cardiac assist device? |
30 degrees max for at least 6 hours after sheath removal |
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Procedure for taking patients off cardiac assist device? |
Wean patient off slowly. Monitor hemodynamics Manual compression to site Assess access site for complications Check pedal pulses Bed rest |
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What is ECMO? |
Extra-Corporeal Membrane Oxygenation |
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Survival rate for patients on ECMO? |
50-70% survival rate |
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When is ECMO indicated as a cardiac assist device? |
Last ditch effort in the failing heart |
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Is ECMO inserted/removed in the Cath Lab? |
No, it is done by a surgeon |
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Contraindications for ECMO? |
None other than quality of life after recovery |
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ECMO complications |
Pulmonary Embolism Bleeding at entry site Cardiac thrombosis Heparin Induced Thrombocytopenia (HIT) |
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Signs & symptoms that patient's blood gasses may be off. |
Signs: vital signs Symptoms: distress, dyspnea, cyanosis, diaphoresis |
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What are we measuring with ABGs? |
The balance of acids and bases in the blood (homeostasis of the body) |
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How is pH (Hydrogen ion levels) balanced? |
Metabolic and respiratory processes working together |
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Type of breathing associated with respiratory acidosis? |
Limited deep respirations, fast and shallow (severe asthma type breathing) |
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Type of breathing associated with respiratory alkalosis? |
Deep and rapid (exercise type breathing) |
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Difference between CO2 levels and respiratory acidosis vs. respiratory alkalosis? |
High CO2 = respiratory acidosis Low CO2 = respiratory alkalosis |
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Aspirin toxicity may cause which type of ABG imbalance? |
Respiratory alkalosis |
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Anesthesia may cause which type of ABG imbalance? |
Respiratory acidosis |
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Electrolytes are involved with this type of ABG imbalance. |
Metabolic |
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Volume of air is involved with this type of ABG imbalance |
Respiratory |
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Toxins, Carbon Monoxide poisoning, Alcohol intoxication may cause this type of metabolic ABG imbalance. |
Metabolic acidosis |
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Low potassium may cause this type of metabolic ABG imbalance |
Metabolic alkalosis |
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High HCO3 (bicarbonate) levels are associated with this type of ABG imbalance |
Metabolic alkalosis
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Low HCO3 (bicarbonate) levels are associated with this type of ABG imbalance |
Metabolic acidosis |
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Normal pH range is |
7.35 to 7.45 where 7.0 is neutral (neither acidotic nor alkaline) |
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Normal CO2 (carbon dioxide) range is |
35-45 mm Hg |
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CO2 levels may change (rapidly/ slowly) and are (directly/ inversely) proportional to pH. |
Rapidly inversely |
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Increased CO2 by itself has this effect on pH |
Lowers pH (respiratory acidosis) |
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Decreased CO2 by itself has this effect on pH |
Raises pH (respiratory alkalosis) |
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Fast and deep breathing (decreased rate and depth) has this effect on ABGs |
Decreases CO2 Raises pH Respiratory alkalosis |
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Slow and shallow breathing (increased rate and depth) has this effect on ABGs |
Increases CO2 Lowers pH Respiratory acidosis |
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HCO3 (bicarbonate) levels are regulated by which organ(s) |
kidneys / pancreas |
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HCO3 (bicarbonate) levels change (slowly/ rapidly) and are (directly/ inversely) proportional to pH. |
Slowly Directly |
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Normal HCO3 range is |
22-26 meq/L |
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Steps in evaluating ABGs (five steps) |
1) Within normal ranges? 2) Is pH high (alkalosis) or low (acidosis)? 3) Is CO2 level out of range? (yes = respiratory imbalance) 4) Is HCO3 level out of range? (yes = metabolic imbalance) 5) Is there compensation? (look for a change in the buffering system NOT involved in primary problem) |
