4) Monitoring & Induction

limb restrictions denoted with a…

pink band

examples of limb restrictions

lymph node dissections, AV fistula/graft

heart conduction pathway

sinus (SA) node → AV node → bundle of his → left & right bundle branches → purkinje fibers

SA node sends electrical pathways to ________ atria

both

define valve stenosis

stiff valve causing extra work of the chamber prior to it

define regurgitation

valve allows blood to leak from ventricle back up to atria

what event is associated with p-wave and what happens as a result of it?

atrial depolarization, contraction follows

what event is associated with QRS interval?

ventricular depolarization

extended PR interval is indicative of…

delayed conduction from SA to AV node

widened QRS interval is indicative of…

delayed ventricular conduction

what event is associated with t-wave?

ventricular repolarization

bipolar leads measure…

potential difference between 2 recording electrodes

bipolar leads come from…

einthoven’s triangle

in Einthoven’s Triangle, the right arm is always…

negative

in Einthoven’s Triangle, the left leg is always…

positive

in Einthoven’s Triangle, the left arm is…

positive from right arm and negative from left leg

in Einthoven’s Triangle, which lead lines up best with initial pathway of conduction in the heart?

II

as the electrical conduction travels up the purkinje fibers, there is a ________ in the ECG graph

downstroke

ECG: where is the j(unction) point?

end of QRS and beginning of ST segment

why is the ST segment important?

useful in determining if patient is having heart attack or ischemia

why is ischemia considered a supply and demand issue?

you can have normal supply, but increased demand or decreased supply and normal demand

ischemia is indicated on ECG by…

ST depression

infarcted tissue is indicated on ECG by…

ST elevation

unipolar (V) leads assess…

electrical fields in horizontal plane of chest

V1 placement

4th intercostal space, right of sternum

V2 placement

4th intercostal space, left of sternum

V3 placement

midway between V2 and V4

V4 placement

5th intercostal space, midclavicular line

V5 placement

5th intercostal space, anterior axillary line

V6 placement

5th intercostal space, midaxillary line

V2 and V5 best encapsulate…

heart function, specifically LV function

what 3 main electrolytes go in and out of the myocardial cell during an action potential?

sodium, potassium, calcium

Ca channel blockers slow depolarization of…

SA and AV nodes

Na channel blockers slow depolarization of…

purkinje fibers, delaying impulse to atrial/ventricular muscle cells

how long is a normal QRS?

0.2 sec

LV hypertrophy is indicated on ECG by…

larger r-waves in lateral leads V5 and V6 than other areas of the heart

each small box on the ECG = _________ sec

0.04

each big box on ECG = ________ sec

0.2

rate from ECG formula

rate = 300 / # of boxes between r-waves

define sinus tachycardia

HR > 100bpm

define sinus bradycardia

HR =< 60 bpm

atrial fibrillation

chaotic atrial depolarization that doesn’t allow the SA node to pace at a normal rhythm

in afib, what wave isn’t seen?

p-wave

afib results in…

pooling/blood clots in atria, leading to stroke

treatment for afib

blood thinners or cardioversion

define junctional rhythm

electrical signal originates from AV node or bundle of his instead of SA

in junctional rhythms, what wave isn’t seen?

p-wave

premature ventricular complex (PVC)

ventricular conduction when not filled, so no blood ejected (no pulse)

ventricular trigeminy

PVC every 3rd

what to do when ventricular bigeminy is observed?

immediate cardiac consult

pulsatile ventricular tachycardia treatment

cardioversion

non-pulsatile ventricular tachycardia treatment

shock

asystole treatment

epinephrine, CPR

ventricular fibrillation

ventricular quivering, no contraction or pulse

ventricular fibrillation treatment

shock

what tissue is being affected when you see ST depression?

endocardium

what tissue is being affected when you see ST elevation?

endocardium, myocardium, epicardium (transmural MI)

too tight of a BP cuff provides incorrectly ________ readings

high

too loose of a BP cuff provides incorrectly ________ readings

low

oscillometry measures…

mean pressure and calculates systolic and diastolic

Korotkoff sounds measure…

systolic and diastolic

invasive blood pressure measures…

mean, systolic, diastolic

MAP > ____ mmHg will ensure adequate renal perfusion

80

MAP > ____ mmHg will ensure adequate cerebral perfusion

50

Beers-Lambert Law relates…

solute (hemoglobin) concentration to intensity of light transmitted through solution

oxyhemoglobin absorbs ________ light at ____ nm and transmits ________ light at ____ nm

infrared, 940, red, 660

de-oxyhemoglobin absorbs ________ light at ____ nm and transmits ________ light at ____ nm

red, 660, infrared, 940

pulsatile flow waveform

plethysmography

pulse ox > 80% is…

true and calculated

slowly decreasing EtCO₂ indicates…

circulatory issue (hypotension, decreased cardiac output)

an immediate decrease in EtCO₂ indicates…

pulmonary embolism

respiratory gas analysis measures…

EtCO2, inhalational agents, fresh gases, inspired/expired levels

A-B

breathing out dead space

D-E

inspiration

D

reading of capnometry

B-C

dead space and alveolar air mixing

C-D

pure alveolar air

slow rate of rise seen from B-C indicates…

COPD, acute airway obstruction (bronchospasm)

how does neostigmine work to reverse paralysis?

decreases cleavage of ACh at NMJ, allowing it to overcome NDMR

neuromuscular monitoring is a ________ assessment that measures…

qualitative, effect of neuromuscular blockers (paralytic agents)

how many twitches is enough for neostigmine to get a patient breathing on their own?

1

Train of Four (TOF) = ____ equal stimuli at ____

4, 2 Htz

sustained tetany = ________ stimulus at ____

continuous, 50 Htz

the recommended site for neuromuscular monitoring is…

ulnar nerve

response of neuromuscular monitoring at ulnar nerve

adductor pollicis muscle

why is the ulnar nerve recommended for neuromuscular monitoring?

closely indicates diaphragm paralysis

response of neuromuscular monitoring at facial nerve

orbicularis occuli muscle

neuromuscular monitoring at facial nerve most closely indicates…

vocal cord paralysis

response of neuromuscular monitoring at posterior tibial nerve

plantar flexion of flexor hallucis

bispectral index (BIS) measures…

depth of anesthesia by brain activity

how long does a patient need to be able to lift their head off the table to be confident that they can breath on their own?

5 sec

BIS < ____ indicates brain function shutting down (________)

20, burst suppression

BIS between ________ is ideal for ________

40-60, no recall or response

when to use TIVA?

h/o PONV, family history of malignant hyperthermia, neuro-monitoring needed

BIS monitoring is useful alongside what anesthetic technique?

TIVA

transesophageal echocardiography (TEE) measures…

cardiac function (regional wall motion abnormalities, ischemia) and volume status (ventricles full, empty)

central venous pressure (CVP) measures…

right ventricular filling pressure

central venous pressure (CVP) indicates…

cardiac volume

a

atrial contraction

c

ventricular contraction