Term
| Paradoxical Splitting of S2: Which Murmurs are Known to have Paradoxical Splitting of S2? |
|
Definition
HOCM, L BBB, R. VENT. PACING, AS, PS (Remember: "HL RAP") Paradoxical Splitting of S2 |
|
|
Term
Pulse Waves: Large Left a-waves Attenuated y-decent (LLaw + Ayd) |
|
Definition
Mitral Stenosis (LLaw + Ayd = MS) |
|
|
Term
Pulse Waves: Large Right v-waves |
|
Definition
"TR" Tricuspid Regurgitation |
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|
Term
Pulse Waves: Large Right Jugular a-waves |
|
Definition
|
|
Term
| Pulse Waves: Pulses Thready |
|
Definition
| Acute Aortic Regurgitation "AAR" |
|
|
Term
Pulse Waves:
Corigan Pulse or Waterhammer Pulse |
|
Definition
Chronic Aortic Regurgitation
"CAR" |
|
|
Term
Pulse Waves:
Slowed Carotid Upstroke |
|
Definition
|
|
Term
Pulse Waves:
Brisk Caroid Upstroke
2/3 are Bifid |
|
Definition
|
|
Term
Pulse Waves:
Large Left v-waves |
|
Definition
Acute Mitral Regurgitation
"AMR" |
|
|
Term
Murmurs and Clicks:
List All the Murmurs with Clicks |
|
Definition
AS/PS = ejection click....
MVP/CAR= Mid Systolic Click....
Mitral Stenosis = Only Diastolic Click.....
(MVP= Mitral Valve Prolapse)..
(CAR= Chronic Aortic Regurg)..
SEM= Systolic Ejection Murmur |
|
|
Term
Murmurs and Clicks:
MSC->SEM |
|
Definition
|
|
Term
Murmurs and Clicks:
MSC->Late SEM |
|
Definition
CAR
Chronic Aortic Regurgitation |
|
|
Term
| Murmurs and Clicks: Only diastolic click Opening Snap |
|
Definition
|
|
Term
| When Do MVP patients need antibiotic prophylaxis? |
|
Definition
| Only when associated with a murmur or myxomatous leaflets. |
|
|
Term
| Name two murmurs associated with clicks. "Click Murmur Syndrome" |
|
Definition
|
|
Term
| How do you tell the difference between an ejection click (seen with AS/PS) and a mid-systolic click (msc)? (seen with MVP/CAR) |
|
Definition
| EJECTION clicks are fixed and do not vary with the position of the patient. A MID-SYSTOLIC Click will vary all over systole with the change in the patients position. |
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|
Term
| When does a Mid-Systolic Click and an Ejection click sound the same? |
|
Definition
| When Standing. In the Supine position a mid-systolic click (msc) will occur later in systole. |
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|
Term
| There is only one DIASTOLIC CLICK what is the murmur associated with it? |
|
Definition
| Mitral Stenosis (the opening snap) |
|
|
Term
| What is the most common valve problem seen in the office? |
|
Definition
| MVP (Remember MVP has a systolic click) |
|
|
Term
| Which MVP patients have an increased risk of infective endocarditis and sudden death? |
|
Definition
| The same ones that need antibiotic prophylaxis. Only with associated murmur or myxomatous leaflets. |
|
|
Term
| List some Cardiac causes for Cerebral Embolic Events: |
|
Definition
| 45%= A-Fib... 15%= MI... 10% =Vent. Aneurysm... 10% =Mechanical Valves... 10% =Valvular Heart Disease... Other = Patent Foramen Ovale...Dilated Cardiomyopathy which leads to Thrombus. |
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|
Term
| When do you anticoaulate patients with Heparin/Coumadin? |
|
Definition
| MI...Cardiomyopathy...Mechanical Valve...Rheumatic Valve Disease |
|
|
Term
| What is the #1 cause of Acute Mitral Regurge? ("AMR") |
|
Definition
|
|
Term
| Beside Endocarditis list two other causes of AMR...Acute Mitral Regurge... |
|
Definition
| Papillary Muscle Rupture secondary to MI...and Ischemia of the Tip of the Papillary Muscle which can induce the chordae tendineae to pull free causing an Acute Mitral Regurg simulating a Ruptured chordae tendineae. |
|
|
Term
| Word Association:...Diastolic Rumble... |
|
Definition
|
|
Term
| Word Association:...SHORT Diastolic Rumble... |
|
Definition
| Acute Aortic Regurgitation |
|
|
Term
| Word Association:...Ejection Click with no specific murmur... |
|
Definition
|
|
Term
| Word Association:...LLSB/Systolic |
|
Definition
| Tricuspd Regurgitation (TR) |
|
|
Term
| Word Assoociation:...LSB/Diastolic |
|
Definition
|
|
Term
|
Definition
| Loudest over the APEX and LLSB |
|
|
Term
|
Definition
| Mitral Stenosis with Pliable Leaflets...with INcreased Diastolic Flow Rate. |
|
|
Term
|
Definition
| Acute Aortic Regurgitation...with a LONG PR interval. |
|
|
Term
| What do you call the sound made when the Mitral and Tricuspid valves close? |
|
Definition
|
|
Term
| What do you call the sound made when the Aortic and Pulmonary valves close? |
|
Definition
|
|
Term
|
Definition
|
|
Term
| When S2 is heard in the APEX...what does this indicate? |
|
Definition
|
|
Term
| When is S2 increased...with Inspiration or Expiration? |
|
Definition
| S2 increases with inspiration.....decreases with expiration. |
|
|
Term
| What is another term for "Ventricular Galop"? |
|
Definition
|
|
Term
|
Definition
| Aply the BELL lightly to the Apex (LVS3) and the LLSB (RVS3) |
|
|
Term
| Is S3 Hight or Low Frequency? |
|
Definition
| LOW (This is the reason for using the BELL) |
|
|
Term
| What is another name for "Atrial Galop"? |
|
Definition
|
|
Term
| Forceful Atrial Contractions will cause this sound... |
|
Definition
|
|
Term
| List murmurs associated with a S3... |
|
Definition
| MR...VSD...AR...HOCM...Restrictive Cardiomyopathy...Constrictive Pericarditis |
|
|
Term
| List Murmurs associated with a S4... |
|
Definition
| AS...HOCM...AR-acute...Dilated Cardiomyopathy...LVH |
|
|
Term
| Is a Diastolic Murmur ever Normal? |
|
Definition
| NO! A systolic Murmur may be innocent however a Diastolic Murmur is always guilty!! |
|
|
Term
| Word Association...DE-crescendo LOW pitched RUMBLE |
|
Definition
|
|
Term
| What is "Lutembacher"s syndrome? |
|
Definition
| Mitral Stenosis (usually rheumatic) associated with:....Atrial Septal Defect. |
|
|
Term
| Word Association...Right Ventricular Heave |
|
Definition
|
|
Term
| This murmur will radiate to the Axilla if a central jet is present.... |
|
Definition
|
|
Term
Word Association... Late Systolic Parasternal Lift on Palpation Which Murmur is this? |
|
Definition
|
|
Term
| Palpable Thrill...think of |
|
Definition
|
|
Term
| Left Second ICS think of... |
|
Definition
|
|
Term
| How do you describe the "Innocent Murmur"? |
|
Definition
| Soft...Crescendo-Decrescendo...best heard at the BASE...MID-Systolic...NO radiation...NO maneuvers...NO associated findings! |
|
|
Term
| This Murmur is loudest at the BASE...Radiates to the Carotids...Decreased with Hand Grip...Increased with Standing...Late Peaking |
|
Definition
| The pulse is probably Bi-Fid also and this is HOCM. |
|
|
Term
| This Murmur is loudest at the LEFT Sternal Border...Radiates to the Lower RIGHT Sternal border...Increases with Inspiration...Prominent V-wave in neck. |
|
Definition
|
|
Term
| What type of splitting of S2 usually occurs with a pulmonary embolus? |
|
Definition
|
|
Term
| Pulsus Bisferiens is seen with... |
|
Definition
| AR and HOCM. ...Bifid pulse with two aortic peaks. |
|
|
Term
| What is Pulsus Alternans and what is it associated with? |
|
Definition
| Bigeminal premature ventricular contractions (PVC's)...and severe LV dysfunction.... Alternately Strong and Weak Pulses @ Regular Intervals. Sometime detected in the Brachial Radial Pulses by deflating the BP cuff where the Pulse Sounds double with the cuff release. |
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|
Term
| What is a Dicrotic Pulse? |
|
Definition
| An exaggerated Dicrotic Wave following the Dicrotic Notch...caused by the Aortic Valve Closure...Associated with LOW Cardiac Output...Low Peripheral Resistance....Seen in Heart Failure and Hypo volemic shock. |
|
|
Term
| What is a normal RA pressure? |
|
Definition
|
|
Term
| What is a normal PA pressure |
|
Definition
|
|
Term
|
Definition
|
|
Term
| When do you see Large a-Waves? |
|
Definition
| MS...PS...TS...Severe noncompliant RVH |
|
|
Term
| What produces a rapid X and Y decent? |
|
Definition
| Constrictive Pericarditis |
|
|
Term
| What produces a rapid X decent? |
|
Definition
|
|
Term
| Large a and v wave with R heart failure... |
|
Definition
| Pulmonary HTN ...(from any cause of chronic RHF) |
|
|
Term
| Large v-waves, with + Kussmaul's sign... |
|
Definition
|
|
Term
| Large V waves, (No Kussmaul's sign)... |
|
Definition
|
|
Term
| Large a waves, slow y descent, but POSITIONAL and may have a "plop" sund with change in position.... |
|
Definition
|
|
Term
| Rapid X Descent, Pulsus Paradoxus... |
|
Definition
|
|
Term
| Rapid X and Y Descents, Kussmaul's sign, may have a diastolic knock.... |
|
Definition
| Constrictive Pericarditis |
|
|
Term
| Rapid X and Y descents, Kussmaul's sign, but NO KNOCK and other manifestations of a Pirmary Illness.... |
|
Definition
| Restrictive Cardiomyopathy |
|
|
Term
| Large, possibly unilaterally, Nonpulsatile, neck veins: may have facial edema and cyanosis... |
|
Definition
| Superior Vena Cava Syndrome |
|
|
Term
| Large Nonpulsatile neck veins, severe dyspnea and chest pain, unilateral lack of breath sounds. |
|
Definition
|
|
Term
|
Definition
|
|
Term
| Knock, Knock, Knock (Diastolic)...who is there? |
|
Definition
| Constrictive Pericarditis |
|
|
Term
| What is this:...a patient with an EJECTION CLICK and a PROMINENT A WAVE, which is caused by backflow during atrial contraction against an inadequately emptied right ventricle. |
|
Definition
| Pulmonic Stenosis...is virtually always congenital, and it typically does NOT progress. |
|
|
Term
| Pulmonic regurgitation is usually secondary to what? |
|
Definition
| PR is usually 2ndary to Pulmonary HTN (primary, cor pulmonale, MS, etc.) but it may be a primary vave lesion (congenital, rheumatic heart disease, endocarditis, carcinoid). Pulmonary artery pressure is > 60 mmHg in pts with secondary pulmonic regurgitation. |
|
|
Term
| Describe the Ebstein anomaly: |
|
Definition
| the Tricuspid septal leaflet is REDUNDANT and positioned LOWER in the ventricle than normal...so the RA appears HUGE and the RV small. Tricuspid regurg (TR) murmur is common. It is occasionally associated with both PSVT and WPW syndrome. |
|
|
Term
| the Tricuspid septal leaflet is redundant and positioned lower in the ventricle than normal.. |
|
Definition
|
|
Term
| This is occasionally associated with both PSVT ans WPW syndrome... |
|
Definition
|
|
Term
| When is valve surgery indicated for any valve problem...? |
|
Definition
|
|
Term
| What is the procedure of choice in pulmonic valve stenosis? |
|
Definition
|
|
Term
| Balloon valvuloplast is the procedure of choice for what? |
|
Definition
| Pulmonic valve stenosis but it is used on Mitral and infrequently on Aortic valves also. |
|
|
Term
| Is there arterial embolization associated with Balloon valvuloplasty? |
|
Definition
|
|
Term
| Which is generally better?... Valve Replacement or Valve repair? |
|
Definition
|
|
Term
| What is the best surgical treatment for Mitral Regurgitation (MR)? |
|
Definition
| Valve Reconstruction when ever possible because it has 1/2 the surgical risk of MV prosthesis. Reconstruction is valve repair and or annuloplasty with an annuloplasty ring, and is especially likely to be done with MVP due to rheumatic fever. |
|
|
Term
| Bigimini & Severe LV dysfuction you see this pulse pattern in.... |
|
Definition
|
|
Term
| What is the difference between a Dicrotic pulse and Bisferiens pulse? |
|
Definition
| Dicrotic pulse (which is a pulse with exaggerated dicrotic wave) literally means twice beating pulse, like bisferiens pulse. However, the dicrotic pulse has the second pulse during diastole, while the bisferiens pulse has the second pulse during systole. |
|
|
Term
| What is a Dicrotic Pulse? |
|
Definition
| A pulse appearing in the blood pressure wave during the diastolic phase. |
|
|
Term
| Where is S2 loudest in Pulmonary HTN and ASD? |
|
Definition
|
|
Term
| Where is S2 normally Loudest? |
|
Definition
|
|
Term
| Is LLSB associated with S1 or S2? |
|
Definition
|
|
Term
| Is LUSB associated with S1 ot S2? |
|
Definition
| S2 (Remember 2 is a higher number and S2 is upper sternal boarder left side)...However S2 is also more "basic" ie heard at the BASE and LUSB. |
|
|
Term
| Which is normally heard in the APEX...S1 or S2? |
|
Definition
|
|
Term
| List 4 possible causes of HoloSystolic (Pansystolic) Murmurs: |
|
Definition
| Holosystolic murmurs accompany (1) mitral or (2) Tricuspid REGURGITATION; (3)VSD; ..(4) and under certain circomstances aortopulmonary shunts. .....MR,TR,VSD,AP shunts |
|
|
Term
| What will increase the holosystolic murmurs of MR & VSD? |
|
Definition
|
|
Term
| What will increase the Holosystolic murmur of Tricuspid Regurgitation (TR) associated with Pulmonary HTN? |
|
Definition
| The murmur of TR with Pulm HTN is increased with INspiration and is holosystolic. |
|
|
Term
| What percentage of Normal Patients with NO clinical heart disease have valvular regurgitation on echo? |
|
Definition
| 88% = Pulmonic...70% = Tricuspid and 45% Mitral. Aortic regurgitation is encountered much less frequently in normal persons, and its incidence increases with advancing age. Overinterpretation of the signifcance of mild regurgitation by echocardiographers is called "echocardiographic heart disease" (Harrisons) |
|
|
Term
|
Definition
|
|
Term
| What is another name for Mid-systolic Murmur? |
|
Definition
| Systolic Ejection Murmur is another name for midsystolic murmur. Systolic Ejection Murmurs are MIDsystolic. |
|
|
Term
| Name the "prototype" for the left-sided midsystolic murmur.... |
|
Definition
|
|
Term
| Where is the murmur of Valvular Aortic Stenosis usually loudest? |
|
Definition
|
|
Term
| Where is the Mumur of SupraValvular Aortic Stenosis loudest? |
|
Definition
| 2nd Right ICS or even higher, with disproportionate radiation into the right carotid artery. |
|
|
Term
| Where is the murmur of HOCM usually loudest? |
|
Definition
| This midsystolic murmur originates in the left ventricular cavity and is usually maximal at the lower left sternal edge and apex. (LLSB & Apex) |
|
|
Term
| When is MR or less frequently TR heard as an ejection murmur (ie. Midsystolic)and not Holosystolic? |
|
Definition
| With papillary muscle dysfunction. Such murmurs due to papillary muscle dysfunction with mitral regurgitation are often confused with those originating in the aorta, particularly in elderly patients. |
|
|
Term
| When observing the jugular venous pulse...which vein is ordinarily examined? |
|
Definition
|
|
Term
| When observing the Jugular Venous Pulse which side (Left or Right) is used and why? |
|
Definition
| Right....the right innominate and jugular veins extend in an almost straight line cephalad to the superior vena cava, thus favoring transmission of hemodynamic changes from the right atrium, whereas the left innominate vein is not in a straight line and may be kinked or compressed by a variety of normal structures, by a dilated aorta, or by an aneurysm. |
|
|
Term
| At what angle should the patients position be to examine the JV pulse? |
|
Definition
| 45 degrees. However 60 - 90 degrees are required to see pulsations when the patients has high venous pressure. If the venous pressure is high place the patient higher...if the venous pressure is low place the patient lower. |
|
|
Term
| What muscle crosses the internal jugular vein? |
|
Definition
| Sternocleidomastoid muscle |
|
|
Term
| What are the visible difference between the Carotid arterial pulse and the Jugular venous pulse in the neck? |
|
Definition
| The arterial (Carotid) pulse has a single upstroke....The Venous (Jugular) has TWO PEAKS and TWO TROUGHS per cardiac cycle....The Carotid pulse does not change with the patient position....Compression of the root of the neck stops the Jugular but not the Carotid pulse....The Jugular usually disappears with a palpating finger. |
|
|
Term
| In the Jugular Venous Pulse what causes the A wave? |
|
Definition
|
|
Term
| In the Jugular Venous Pulse what causes the X wave? |
|
Definition
|
|
Term
| In the Jugular Venous Pulse what causes the C wave? |
|
Definition
| The Carotid Arterial Pulse = C wave of JVP |
|
|
Term
| What wave is between the X and X' descent? |
|
Definition
| The C wave:... which occurs simultaneously with the carotid arterial pulse, is an inconstant wave in the jugular venous pulse and/or interruption of the X descent after the peak of the A wave. The continuation of the X descent after the C wave is referred to as the X' descent. |
|
|
Term
| In the Jugular Venous Pulse what causes the V wave? |
|
Definition
| The Tricuspid valve is CLOSED and the ventricle is contracting!...this increases the right atrial pressure and causes the V-wave. |
|
|
Term
| In the Jugular Venous Pulse what causes the Y descent? |
|
Definition
| The tricuspid valve reopens...This is the downslope of the V-wave. ...Caused by the decline in right atrial pressure when the tricuspid valve reopens. |
|
|
Term
| In the Jugular Venous Pulse what causes the Y TROUGH? (This is after the Y descent) |
|
Definition
| This is a period of relatively slow filling of the atrium or ventricle, "the diastasis period", a wave termed the H wave. |
|
|
Term
| In the Jugular Venous Pulse during Inspiration, what happens to the jugular venous pressure and the amplitude of the pulsations? |
|
Definition
| The pressure goes down but the amplitude of the pulsations go up! If the pressure goes up the you have Kussmaul sign!! (paradoxical rise in the height of the jugular venous pressure during inspiration. |
|
|
Term
| What do you call the waves created when the right atrium contracts against a closed tricuspid valve? |
|
Definition
| Cannon (amplified) A waves....caused by AV dissociation. |
|
|
Term
| Re: the Jugular Venous Pulse what causes the A wave and X descent to disappear? (they really should not do this!) |
|
Definition
|
|
Term
| In the Jugular Venous Pulse what will cause Tall A waves? (Pt. with Sinus Rhythm) |
|
Definition
| Tricuspid Stenosis or Atresia....Right Atrial Myxoma....Reduced compliance / hypertrophy of the right ventricle...Pulmonary HTN.... (TS..TA..RVH..Pulm. HTN..)... any condition in which the resistance to right atrial contraction is increased. |
|
|
Term
| What does this describe?...a rapid and deep Y descent followed by a rapid rise to a diastolic plateau (H wave) without a prominent A wave...the X descent may or may not be prominent.>>>>> |
|
Definition
| Constrictive pericarditis... |
|
|
Term
| Which has the most prominent X descent...Constrictive pericarditis or Tamponade? |
|
Definition
|
|
Term
| What causes systolic movements of the earlobes...a prominent V wave or C-V wave (fusion of the C and V waves in the absence or attenuation of an X descent)? |
|
Definition
| Tricuspid regurgitation (TR) |
|
|
Term
| What causes a steep Y descent (Jugular Venous Pulse)? |
|
Definition
| Ventricular Dilation, Elevated CVP, or any condition in which there is myocardial dysfunction. |
|
|
Term
| The venous pulse contour in this heart problem often takes on an M or W configuration? What is it>>>>> |
|
Definition
| Constrictive Pericarditis |
|
|
Term
| murmur of the 2nd R. IC space radiates to the carotid arteries... |
|
Definition
|
|
Term
| murmur loudest in the APEX...radiates to the LEFT STERNAL BORDER and base of the heart... |
|
Definition
| (MR)..Mitral Regurg...if it radiates to the base of the heart then the posterior mitral leaflet is predominantly involved. |
|
|
Term
| the RA appears HUGE and the RV small |
|
Definition
|
|
Term
a rapid and deep Y descent followed by a rapid rise to a diastolic plateau |
|
Definition
| Constrictive pericarditis |
|
|
Term
| occurs simultaneously with the carotid arterial pulse, is an inconstant wave in the jugular venous pulse and/or interruption of the X descent after the peak of the A wave |
|
Definition
|
|
Term
Beginning of Iso-Volumetric Contraction... simultaneously with Tricuspid Valve Closure 2ndary to RV Contraction.... Best seen in AV Block and LBBB... |
|
Definition
|
|
Term
|
Definition
| X decent = Atrial Diastole |
|
|
Term
|
Definition
| Right Ventricular Contraction = X' descent |
|
|
Term
During Systole there is Atrial Filling from the Vena Cava which causes the Atrial Pressure to Rise against a closed Tricuspid Valve and generates this wave...Name this wave... |
|
Definition
V wave = Closed Tricuspid Valve in Systole Increased Atrial Filling Pressures |
|
|
Term
| Ventricular systole ends and the ventricle expands generating this wave...Name this wave... |
|
Definition
|
|
Term
| Mitral Stenosis (the opening snap) |
|
Definition
Pulse Waves:  Large Left a-waves Attenuated y-decent  (LLaw + Ayd)  Only diastolic click Opening Snap |
|
|
Term
If you are giving supplemental O2
then how do you calculate the DA-a O2 ? |
|
Definition
PAO2 =
[ ( 713 mmHg ) x ( FiO2 ) ] - [1.25 x PaCO2 ]
PaCO2 in the above equation is from the ABG value
(for standard: sea level and norm. temp.)
Plug the FiO2 into the above formula for PAO2 then use:
DA-a O2 = PAO2 – PaO2
(just subtract the ABG value of PaO2 in the bottom equation
From the value calculated in the top line of this card) |
|
|
Term
| The 6 causes of Hypoxemia? |
|
Definition
V/Q mismatch
R - L Shunting*
Low Mixed venous
Hypoventilation
Decreased diffusion
High altitudes
*Supplemental O2 does not help
increase the PaO2 with R-toL shunting
A-a gradient is normal with hypoventilation and high altitudes |
|
|
Term
What happens to the A-a gradient with
hypoventilation?
high altitudes? |
|
Definition
A-a gradient
is normal with hypoventilation and high altitudes
Nothing really happens: to the A-a gradient |
|
|
Term
D(A-a) O2 is increased in all causes of hypoxemia
except what? |
|
Definition
| Hypoventilation & High Altitude |
|
|
Term
What are the 6 causes of Hypoxemia?
Which one will not improve with supplemental O2? |
|
Definition
V/Q mismatch
R - L Shunting*
Low Mixed venous
Decreased diffusion
Hypoventilation
High altitudes
*Supplemental O2 does not help
increase the PaO2 with R-toL shunting
A-a gradient is normal with hypoventilation and high altitudes |
|
|
Term
What is important to the TISSUE
regarding Oxygen: |
|
Definition
"Transportation & Utilization"
How much
O2 is transported to tissue
&
How much
O2 is taken up and utilized
by the
mitochondria and/or cells |
|
|
Term
| Symbol for O2 transport to the tissue = ? |
|
Definition
|
|
Term
| Symbol for Oxygen content of arterial blood? |
|
Definition
| CaO2 = Oxygen content of arterial blood |
|
|
Term
What is important to the tissue
regarding oxygen: |
|
Definition
How much O2 is transported to tissue
&
How much O2 is taken up and utilized by
the mitochondria and/or cells
"Transportation & Utilization"
How much
O2 is transported to tissue
&
How much
O2 is taken up and utilized
by the
mitochondria and/or cells |
|
|
Term
What is important to the tissue
regarding oxygen: |
|
Definition
transportation
&
utilization |
|
|
Term
DO2 = oxygen transport to the tissue
DO2 depends on what 3 factors?
|
|
Definition
Cardiac output
Hemoglobin level
Hemoglobin saturation
DO2 = oxygen transport to the tissue
DO2 = Cardiac output x (CaO2)
(CaO2 = Oxygen content of arterial blood) |
|
|
Term
In board questions, you are typically given
a crtically ill patient with either
cardiac output or Hgb level obviously low
and a SaO2 which is 90% with a PaO2 of 60 mmHg.
What is the best thing to do? |
|
Definition
Address the obviously low Hgb or cardiac output.
The PaO2 is fine because the SaO2 is fine.
Remember the 3 factors evaluated
with a critically ill patient:
1: Cardiac output
2: Hemoglobin Level (Hmb)
3: Hemoglobin saturation (SaO2 / PaO2) |
|
|
Term
The oxyhemoglobin dissociation curve
shows the amount of O2 saturation (SaO2)
for a certain ____? |
|
Definition
PaO2
It is the amount of
O2 saturated Hgb
that is important. |
|
|
Term
The actual O2 saturation of a particular
hemoglobin molecule at a particular PaO2
is dependent on what 3 important things? |
|
Definition
Temperature
Erythrocyte 2,3,-DPG level
pH status
The oxyhemoglobin dissociation curve shows
the SaO2 for a certain PaO2---given variation
in the above 3 factors. |
|
|
Term
What will shift the curve to the right?
(O2 Saturation curve) |
|
Definition
TAP
Temperature
Acidosis
Phosphorus |
|
|
Term
Carbon monoxide poisoning:
what effect on the O2-sat. curve? |
|
Definition
there would be NO or minimal effect on the SaO2
with an increace in PaO2.
Blood PO2 measurements tend to be normal because PO2 reflects O2 dissolved in blood, and this process is not affected by CO. In contrast, hemoglobin-bound O2 (which normally comprises 98 percent of arterial O2 content) is profoundly reduced in the presence of COHb.
CO binds hemoglobin stronger than O2.
Carbon monoxide (CO) diffuses rapidly across the pulmonary capillary membrane and binds to the iron moiety of heme (and other porphyrins) with approximately 240 times the affinity of oxygen . |
|
|
Term
| What is reduced in Carbon Monoxide poisoning? |
|
Definition
Hemoglobin-bound O2
(which normally comprises 98 percent of arterial O2 content) is profoundly reduced in the presence of COHb. |
|
|
Term
Why does the PaO2 remain normal
or near normal in Carbon monoxide poisoning?
(CO = carbon monoxide in this question) |
|
Definition
Blood PaO2 measurements tend to be normal because PaO2 reflects O2 dissolved in blood, and this process is not affected by CO.
However this O2 is NOT hemoglobin bound!
The SaO2 (Hmg. saturation) drops.
The PaO2 (O2 partial pressure) doesn't. |
|
|
Term
| What causes Methemoglobin to be produced? |
|
Definition
The Iron in the Hgb molecule
is oxidized from the ferrous to the ferric form.
( Fe++ changes to Fe+++ )
The methemoglobin molecule can no longer
hold onto O2 or CO2, in which very high PaO2
levels results in low SaO2. |
|
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Term
|
Definition
PaO2 = arterial partial pressure of O2
SaO2 = arterial saturation of hemoglobin |
|
|
Term
|
Definition
| Perioral & Peripheral Cyanosis |
|
|
Term
| 35 - 40% Methemoglobinemia? |
|
Definition
|
|
Term
|
Definition
|
|
Term
Treatment of Methemoglobinemia?
(do you feel blue?) |
|
Definition
100% O2
Remove the source.
Methylene blue
Methemoglobin inducers act by oxidizing ferrous (Fe2+) to ferric (Fe3+) hemoglobin. This abnormal hemoglobin is incapable of carrying oxygen, inducing a functional anemia. In addition, the shape of the oxygen-hemoglobin dissociation curve is altered, aggravating cellular hypoxia.
Usually, mild methemoglobinemia (<15–20%) will resolve spontaneously and requires no intervention. Give methylene blue, 1–2 mg/kg (0.1–0.2 mL/kg of 1% solution), over several minutes. Caution: Methylene blue can slightly worsen methemoglobinemia when given in excessive amounts; in patients with G6PD deficiency, it may aggravate methemoglobinemia and cause hemolysis. If methylene blue is contraindicated (eg, G6PD deficiency) or has not been effective, exchange transfusion may rarely be necessary in patients with severe methemoglobinemia. Hyperbaric oxygen is theoretically capable of supplying sufficient oxygen independent of hemoglobin and may be useful in extremely serious cases that do not respond rapidly to antidotal treatment. |
|
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Term
How does methylene blue
reduce the methemoglobin back to hemoglobin? |
|
Definition
Just remember that it does.
Blue people get methylene Blue
Feric(3+) goes back to Ferous(2+)
Give methylene blue,
1–2 mg/kg (0.1–0.2 mL/kg of 1% solution),
over several minutes.
Vitamin C for chronic hereditary methemoglobinemia.
Also the pulse ox will not work for this problem.
Need a "CO-oximeter" |
|
|
Term
What part of the oxyhemoglobin dissociation curve
indicates a "release" of O2, with decreased affinity
between oxygen and hemoglobin, for the local tissues? |
|
Definition
The lower right hand corner of the graph
indicates that a release of oxygen to the tissue
will occur. |
|
|
Term
| Symbol for O2 transport to the tissue = ? |
|
Definition
|
|
Term
Oxygen transport to the tissues depends on
what 3 factors?
DO2 = oxygen transport to the tissue |
|
Definition
Cardiac output
Hemoglobin level
Hemoglobin saturation
DO2 = oxygen transport to the tissue
DO2 = Cardiac output x (CaO2)
(CaO2 = Oxygen content of arterial blood) |
|
|
Term
Anything that shifts the curve
down and to the right has what effect? |
|
Definition
The release of O2 into the tissue.
Working muscles
(+ pCO2 = local acidosis = relase of O2 to the tissues)
(called the Bohr effect)
|
|
|
Term
Metabolic acidosis has what effect on the
oxyhemoglobin dissociation curve? |
|
Definition
When there is systemic acidosis
(or high temp or high 2,3-DPG)
the decrease in affinity for O2 by Hgb
results in less O2 picked up by the Hgb
in the lung, but also more O2 released
in the tissues. So, although the Hgb O2
saturation (SaO2) is lower for a certain PaO2,
more of the oxygen carried by the hemoglobin
is released to the tissue. This dampens but
does not negate, or reverse the effect. |
|
|
Term
|
Definition
| Carbon Monoxide Diffusing Capacity |
|
|
Term
Carbon Monoxide Diffusing Capacity
is decreased by anything that... |
|
Definition
anything that interrups the gas-blood O2 exchange.
(not used much except for board exams!) |
|
|
Term
| A low DLCO implies what (physiologically)? |
|
Definition
A loss of effective, capillary alveolus interface.
Usually due to loss of alveolar-capillary units,
as seen in emphysema, interstitial lung disease
(ILD = DIF, Sarcoidosis, Abestosis)
Pneumonectomy, Pulmonary Vascular problems
such as PE or pulmonary hypertension. |
|
|
Term
| What is the DLCO in Asthma? |
|
Definition
Normal
In Asthma, there is bronchoconstriction,
but no alveolar disease. However it
may be increase with air trapping with bronchospasm. |
|
|
Term
| When is the DLCO increased? |
|
Definition
Heart Failure
Acute Hemorrhage of the Lung
(diffuse alveolar hemorrhage)
Pulmonary Infarct
Idopathic Pulmonary Hemosiderosis (IPH) |
|
|
Term
|
Definition
Diffuse Interstitial Fibrosis
(this is by definition ILD)
ILD = Interstitial Lung Disease
ILD = DIF, Sarcoidosis, Abestosis
|
|
|
Term
How do you differentiate
emphysema from asthma in a younger patient
with air-flow obstruction? |
|
Definition
|
|
Term
| When is a Pulmonary Function Lab needed? |
|
Definition
Pulmonary Function Lab:
To determine: TLC, RV, DLCO,
Methacholine or other challenges
TLC = total lung capacity
RV = Residual Volume
Otherwise, in the office use spirometry,
and determine most of the lung volumes and capacities,
PEFs, Flow-Volume loops and bronchodilator response. |
|
|
Term
What Pulmonary Function Test
(PFT)
is best for diagnosing
INTERSTITIAL lung disease? |
|
Definition
The PFT for ILD = TLC
Total Lung Capacity
Lung biopsy frequently is required to establish the etiology and stage of interstitial lung disease. Lung biopsy is not required to make the diagnosis in all patients with suspected ILD. However, following the initial evaluation, it is frequently not possible to make a definitive diagnosis or to stage the disease without careful examination of lung tissue.
Most of the interstitial disorders have a restrictive defect with reductions in total lung capacity (¯TLC),
functional residual capacity (¯FRC), and residual volume (¯RV)
An interstitial pattern on chest radiograph accompanied by obstructive airflow limitation on lung function testing is suggestive of any of the following processes:
Sarcoidosis
Lymphangioleiomyomatosis
Hypersensitivity pneumonitis
Tuberous sclerosis
COPD with superimposed ILD
Because resting hypoxemia is not always evident and because severe exercise-induced hypoxemia may go undetected, it is important to perform exercise testing with serial measurement of arterial blood gases |
|
|
Term
| How does the TLC change for ILD? |
|
Definition
It decreases
(spirometry can not determine TLC) |
|
|
Term
| What PFT is used to diagnose OBSTRUCTIVE lung disease? |
|
Definition
|
|
Term
| Spirometry cannot determine what PFT? |
|
Definition
|
|
Term
Transbronchial Bx is most useful
for what conditions? |
|
Definition
TBB is most useful for:
Sarcoidosis
Infectious diffuse Infiltrative lung disease. |
|
|
Term
| When is Lung Biopsy required? |
|
Definition
IPF
Idiopathic Pulmonary Fibrosis
requires biopsy for confirmation. |
|
|
Term
| Simple formula for A-a gradient? |
|
Definition
0.3 x Age (years)
or
Age/4 + 4 |
|
|
Term
Name 3 factors that, for a specific PaO2
will cause a decrease in Hmg O2 sat. (¯SaO2) |
|
Definition
LOW Cardiac Output
LOW Hemoglobin level
LOW Hemoglobin saturation
= LOW Hmg O2 sat. (LOW SaO2 |
|
|
Term
What does CO poisoning do to the
Oxyhemoglobin Curve? |
|
Definition
Standard pulse oximetry cannot screen for CO exposure,
as it does not differentiate carboxyhemoglobin from oxyhemoglobin.
Effect of carboxyhemoglobin on measured oxygen saturation by pulse oximetry |
|
|
Term
What are the symptoms that occur with
increasing levels of methemoglobinemia?
What is the treatment? |
|
Definition
Perioral & Peripheral Cyanosis > 25%
Fatigue and Dyspnea = 35 - 40%
Coma, Death > 60%
Treatment = 100% FiO2
Methylene Blue will reduce the Fe from ferric to ferrous. |
|
|
Term
What smaller lung volumes
make up the Vital Capacity? (VC) |
|
Definition
IRV + TV + ERV = VC
(2 RV's with a TV) = VC |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
There are 4 functional volumes
of which the lung is made:
List them... |
|
Definition
IRV
TV
ERV
RV
(3 RVs & a TV)
"one residual, two reserves & a TV" |
|
|
Term
| What is the definition of a "Capacity" in PFTs? |
|
Definition
A "capacity" is equal to 2 or more of the basic volumes:
IRV
TV
ERV
RV
VC = IRV + TV + ERV (top 3)
IC = IRV + TV (top 2)
FRC = ERV + RV (bottom 2) |
|
|
Term
| A Pulmonary Function Lab is needed for what parameters? |
|
Definition
TLC
DLCO
methacholine or other challenge |
|
|
Term
What test is used in the office
to determine most of the lung volumes & capacities? |
|
Definition
|
|
Term
In the office, using Spirometry,
we do NOT measure TLC.
What do we measure? |
|
Definition
|
|
Term
| VC (vital capacity) is made up of what volumes? |
|
Definition
|
|
Term
| What happens to the VC in COPD? |
|
Definition
It is decreased.
However, because the RV is always increased with COPD
the TLC will be increased. Remember: the TLC is NOT measured
with Spirometry, only in the pulmonary function lab can you
determine the RV and TLC |
|
|
Term
You can NOT obtain the TLC with spirometry,
how do you determine the "degree of obstruction"? |
|
Definition
Comparing the FEV1 to the "forced" VC (FVC)
FEV1 / FVC << 0.8 for copd patients
(look for a concave shape on the expiratory flow curve)
IN FLOW-VOLUME LOOPS:
Expiratory goes upward
Inspiratory goes downward |
|
|
Term
Tracheomalacia
Vocal Cord Paralysis
is what type of obstruction? |
|
Definition
Dynamic EXTRA-thoracic
Obstruction with INSPIRATION |
|
|
Term
Endobronchial Tumor
Foreign Body
Is what type of obstruction? |
|
Definition
Dynamic INTRAthoracic
Obstruction with Expiration
Difficulty exhalation |
|
|
Term
In tracheomalacia, the obstruction is
intra or extra thoracic? |
|
Definition
It can be either one.
If Extrathoracic, with abnormal trachea in the neck
it will collapse with increased intrathoracic pressure
during inspiration.
In Intrathoracic, with abnormal trachea within the chest wall,
the trachea will collapse during exhalation. The malacic trachea
collapses on exhalation. |
|
|
Term
Causes of Lower Airway Obstruction
List 4 different diseases |
|
Definition
COPD
Asthma
Bronchiectasis
Cystic Fibrosis |
|
|
Term
Bronchodilator response with PFTs is done
for 2 reasons: |
|
Definition
1: To see if the obstruction responds to treatment.
All beta2-agonists are held for 8 hours prior to tx.
2: To chek the efficacy of current regimen.
Meds are NOT held. If the pt. DOES respond
then they are not on the optimum treatment |
|
|
Term
Bronchoprovocation-challenge testing
is done when? |
|
Definition
Intermittent Asthma-like symptoms.
To verify bronchial hyperractivity *.
Chronic Cough
*Note: If the Asthma-like symptoms are only during certain situations,
like playing a Tuba while marching in the cold air,
then the IMBs like to have you reproduce the situation
and NOT use the Methacholine lab study. In this case
they would have you march the patient around the block
several times while playing a Tuba to reproduce the symptoms.
Then send them to the PFT lab.
This would be the "Bronchoprovocation-challenge".
Also they might have the patient be tested in his work environment
if the Asthma started in an adult, after beginning new or different
working conditions, employment, etc. If the symptoms are more vague
like a chronic cough, then Methacholine might be considered as part of the
PFT lab work-up.
|
|
|
Term
What agents are used with
Bronchoprovocation-Challenge Testing? |
|
Definition
Methacholine
Histamine
Cold Air
Look for a 20% drop in FEV1
In Asthamatics only a very LOW dose is needed.
Non-asthamatic need much larger doses to respond.
Only a 20% drop in FEV1 is needed for the Dx.
Never crash the patient. |
|
|
Term
PFTs are not routine for pre-op exams.
There are certain types of surgery where
they should be done prior to surgery.
List 3 scenarios: |
|
Definition
The surgical procedure is near the diaphragm
(eg. gall-bladder, etc.)
Patient has moderate or worse lung disease.
FEV1 < 1 liter or an elevated pCO2
this indicates a greater post-op pulmonary complication risk.
Lung Cancer or Lung Resection Surgery |
|
|
Term
| What predicted FEV1 indicates high risk post-op morbidity? |
|
Definition
FEV1 < 0.8 L post op = problems
In a patient with a pre-op < 1.6 L, you can estimate
the post-op FEV1 by doing split-lung PFTs (hard to do).
Obtain a quantitative ventilation, or by quantitative perfusion
lung scan. Then multiply the % perfusion (or ventilation)
of what will be left after surgery by the FEV1,
to obtain the estimated post-op FEV1 |
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