CCRN-EKG

Lateral wall (LCA, left circ)

I, aVL and V5, V6

- occlusion of Left circumflex artery

II, III, and aVF

Inferior wall.

RCA. 2nd most dangerous.

Right sided EKG to look for reciprocal changes.

Avoid nitrates and vasodilators and give fluid if confirmed. This is volume dependent.

R sided EKG. Changes in V3R-V6R

V1

Ventricular septum

V2, V3, V4

Anterior wall.

V1-V4

Anteroseptal (LAD).

Most dangerous

BBB

PA catheter is contraindicated with LBBB d/t risk of injury to RBB leading to complete heart block

V1+V6.

WilliaM and MorroW.

Left BBB V1 looks like a W, V6 looks like an M

Right BBB V1 looks like M, V6 looks like W.

Heart auscultation

S1- Tricuspid/mitral valve

S2-Aortic/pulmonic

S3

Lub-dub-da

Sounds like "Sloshing in"

Ventricular gallop.

FVO

S4

Da-Lub-Dub

Sounds like "A-stiff wall"

Blood being forced into a stiff ventricle

Bell of stethoscope over apex

Murmurs

Sten0sis- Valve 0pen

regurg or insufficiency-valve closing issue

Systolic Lub, murmur, dub

Diastolic Lub, dub, murmur.

Heart pressures

RA/CVP-2-8mmHg

RV-15-30/2-8

PA-15-30/8-15

Mean PAP 9-18, (>25=P. HTN)

PAOP- 6-12

PAOP ranges

Normal 6-12

18-20 onset of P congestion

20-25 moderate

26-30 severe

above 30-P edema

Cardiac Output

Measured with thermodilution. Think of thermoster

Normal 4-8L/min

Cardiac index is weight based CO.

CI normal is-2.5-4.3 L/min/m2

PA wave form

A,C,V

A-left atrial contraction

C-closure of mitral valve. Not often seen

V-LV systole, if V wave is higher than a wave=mitral regurg.

Mixed venous oxygen saturation

Serves as an early trouble indicator and can drive changes to care plan

Obtained from PA catheter. Normal values 60-80%

SvO2=increased supply and decreased demand.

Mixed venous oxygen saturation (<60%)

Insufficient supply vs demand

Increased metabolic requirements

-seizures, restlessness, shivering, hyperthermia.

Oxyhemoglobin Dissociation curve (Left)

Hbg more sticky for O2. SvO2>80%

Alkolosis

Hypothermia

Oxyhemoglobin Dissociation curve (Right)

Less affinity for O2, SvO2<60%

Acidosis

hyperthermia

Allen's test

If the hand flushes within 5-15 seconds then the ulnar artery is patent an there is good blood supply.

Flo-trac

Helps recognize fluid status and connects to arterial line

Measures CO and stroke volume variation. SVV normal <13%.

>13% the patient is dry and needs more fluid.

Alternative methods to determining fluid status

Passive leg raise

Clear sight system-SV, Stroke volume variation, CO, SVR, Continuous BP.

Look at Stroke volume index after 250 cc bolus or passive leg raise.

Stroke volume changes with Passive leg raise

Stroke volume increase >10% give fluids

<10% FVO. Myocardium is distended. Consider diuretic

IABP

Bridge to surgery

Augments diastolic BP

Increase Coronary perfusion

Improves CO up to 15%

Must have a-line and EKG input for timing.

IABP cont

Inflates during diastole. Dicrotic notch=aortic valve closing.

Blood forced inferiorly and increases perfusion to distal organs.

Deflates during systole reduces afterload.

decreased O2 demand

IABP complications

Renal perfusion- monitor UOP

Balloon rupture-rapidly diffused gas

Contraindicated in Aortic valve insufficiency, Aortic aneurysms, suspected aortic dissection