PCCN Review – Cardiac Exam (solved)

Calculate the cardiac output for a pt with a HR of 70 and a SV of 65 ml. - ANSWER-HR X SV=CO 70 X 65= 4550 4.6 L/min Calculate the cardiac output for a pt with a HR of 70 and a SV of 65 ml. HR X SV=CO - ANSWER-HR X SV=CO 70 X 65= 4550 4.6 L/min What % of the cardiac cycle is provided by the atrial kick? • 15% • 20% • 30% • 35% - ANSWER-20% Atrial kick is a term that represents the amount of the total CO that is supplied via atrial contraction. If the pt has a condition or dysrhythmia that impairs or eliminates the atrial contraction, the pt may be compromised. Atrial Kick - ANSWER-Atrial kick is a term that represents the amount of the total CO that is supplied via atrial contraction. A normal value for an EF would be? • 65% • 40% • 30% • 25% - ANSWER-65% The EF should be more than 50%. It represents the amount of blood ejected from the left ventricle compared to the total amount available, expressed as a %. An EF of 35% or less indicates a problem with contractility, outflow or filling. EXA: If the ventricle contains 90ml of blood and 50mls are ejected, the amount would be expressed as a %, in this case 55%. A 67 year old male is admitted with chest pain after collapsing at home. He is arguing with his wife that he should not be admitted because he "just over did it" while working in the world. Lee's wife states to you that his chest pain is more frequent, severe and prolonged than before. You should anticipate what diagnosis? • Exertional angina • Unstable angina • Variant angina • Stable angina - ANSWER-UNSTABLE ANGINA The change in quality, frequency, and duration indicates UNSTABLE ANGINA and may indicate that the pt is at increased risk for an MI. This pt should be closely monitored for EKG changes and rhythm disturbances. Pt/ family teaching should begin on how to identify an MI and basic CPR. Stroke Volume is comprised of which of the following factors? • Blood volume, viscosity, impedance • Cardiac output, HR, compliance • Contractility, preload, afterload • Compliance, impedance, HR - ANSWER-Contractility, preload and afterload A reflex tachycardia caused by the stretch of the right atrial receptors is known as the ____ • Herring-Sines law • Renin-angiotensin system • Starling's law • Bainbridge reflex - ANSWER-BAINBRIDGE REFLEX It is believed that this reflex exists to speed up the HR if the right side becomes overloaded, thereby helping equalize pressures on both sides Diastole comprises what & of the cardiac cycle? • ½ • 2/3 • ¼ • 1/3 - ANSWER-2/3 Some people that the heart is virtually static during diastole. During this period, the cardiac vessels and chambers fill—a process that takes up 2/3s of the time necessary to complete the cardiac cycle What is the MAP (mean arterial pressure) for pt: BP 120/70 HR 80 - ANSWER-MAP=2(DBP) + (SBP)/3 MAP=2(70) + 120/3 MAP=260/3 MAP=86.6 Pts should maintain a MAP of at least 60 to ensure adequate perfusion to the brain and kidneys. What is the MAP (mean arterial pressure) for pt: BP 120/70 HR 80 MAP=2(DBP) + (SBP)/3 - ANSWER-MAP=2(70) + 120/3 MAP=260/3 MAP=86.6 Pts should maintain a MAP of at least 60 to ensure adequate perfusion to the brain and kidneys. Calculate CI (cardiac index) HR 80 BP 110/70 SV 60 BSA 2.0 m2 Expressed in L/min/m2 - ANSWER-CI=CO/BSA CO=HR X SV CO=80 X 60 CI=4800/2.0 CI=2400 CI=2.4 L/min/m2 Calculate CI (cardiac index) HR 80 BP 110/70 SV 60 BSA 2.0 m2 Expressed in L/min/m2 CI=CO/BSA - ANSWER-CI=CO/BSA CO=HR X SV CO=80 X 60 CI=4800/2.0 CI=2400 CI=2.4 L/min/m2 The resistance against which the right ventricle must work to eject its volume is known as • Resting heart pressure • Systemic vascular pressure • Central venous pressure • Pulmonary vascular resistance - ANSWER-Pulmonary Vascular Resistance This pressure represents a mean pressure in the systemic vasculature. The higher the resistance, the harder the heart has to work against it. EXA: Colder temperatures will cause vasoconstriction; the heart then has to pump harder to deliver blood through the narrowed vasculature. Mr. Ironclaw lives on a nearby Indian Reservation. He is retired and on a fixed income with no insurance. He is being discharged today after an observational stay for Chest Pain. In planning his discharge care, which of the following should be considered FIRST to increase compliance with plan of care once home? • Arrange for Home Health 1X/week • Ask doc to consider an OTC antiplatelet medication • Schedule his follow-up appt with the cardiologist in 3 months • Suggest a gym membership - ANSWER-ASK DOC TO CONSIDER AN OTC ANTIPLATELET MEDICATION Although he may wish to be compliant with plan of care at home, financial limitations may prohibit him from expensive treatments, meds, and support services. William was diagnosed with unstable angina. He is scheduled for an exercise stress test. He tells you he has a "bad hip" and an old knee injury that makes it difficult for him to walk or stand for more than 20 minutes. You tell him: • You only need to walk for 10 minutes • You can ride a bike for 20 minutes instead • I will call the doc and ask for the Weight-life test instead • I will call the doc and ask for a stress echocardiography test instead - ANSWER-I WILL CALL THE DOC AND ASK FOR A STRESS ECHOCARDIOGRAPHY TEST INSTEAD The exercise stress test requires the pt to walk on a treadmill or stationary bike for 30-60 minutes. The Stress Echocardiography test uses Dobutamine to stress the cardiac tissues without requiring the pt to walk or ride. The Weight lift test does not exist. Approximately what % of coronary artery blockage is needed to cause angina? • 45% • 60% • 75% • 90% - ANSWER-75% Anginal pain usually occurs when approximately 75% of the artery's diameter becomes occluded. Pain is usually more pronounced with exertion or emotional distress, when O2 demand by cardiac tissue cannot be met by O2 supply via the occluded arteries. The severity of the pain may be compounded with vasospams that further restrict blood flow through the coronary arteries. A heart murmur associated with acute valvular regurg would be? • S3 • S2 • S1 • S4 - ANSWER-S4 S1 and S2 are normal heart sounds S3 is associated with fluid status S4 is associated with compliance. Which is the best lead to monitor a RBBB? • Lead II Lead I • Lead V1 • Lead V6 - ANSWER-Lead V1 Tall, peaked T waves on an EKG may be indicative of? • Hypocalcemia • A non-STEMI • Hyperkalemia • A LBBB - ANSWER-HYPERKALEMIA The PR interval may become prolonged. Also, if the K is greater than 8, a wide-complex tachycardia may occur. Keep in mind that low levels of calcium or sodium may potentiate the cardiac effects, as can a low pH. Mrs. P suffered a cardiac arrest at home. The family did not perform CPR and paramedics arrived 6 minutes after the arrest. The pt was found in pulseless V-tach. Defib and continuous CPR were provided during transport to the ED. The pt was tx-ed to tele. The doc initiated hypothermic measures and administered vecuronium. This med is for? • Controlling ventral dysrhythmias • Prevent shivering • Sedative • Pain control - ANSWER-PREVENT SHIVERING Vecuronium is a paralytic and will prevent shivering. If a pt shivers, her temperature will rise. Your pt was admitted for malaise, severe dyspnea and had a syncopal episode at work. He states he has a midline burning sensation in his chest that worsens when he is supine. You suspect? • Pleural effusion • Pericardial tamponade • GERD • Myocarditis - ANSWER-MYOCARDITIS It can also present as inspiratory pain. The pain when supine is a cardinal sign of myocarditis. Other findings may include respiratory infection and an S3, S4, and pericardial friction rub. A definitive diagnosis of myocarditis can be made via? • Endomyocardial biopsy • Transesophageal ultrasound • Transmural catheterization • Chest X-ray - ANSWER-ENDOMYOCARDIAL BIOPSY A biopsy is the ONLY definitive way to diagnose myocarditis. The volume of fluid required to cause a pericardial tamponade is? • 25-50 ml • 50-75 ml • 100-150 ml • 200-300 ml - ANSWER-50-75 ml of blood Although 50-75 mls is a small amount, the pressure in the intrapericardial space may equal or exceed atrial and vertricular pressures causing an acute tamponade. Beck's triad is a combination of symptoms useful in diagnosing cardiac tamponade. They are? • Pericardial friction rub, hypertension, RV failure • Increased pulse pressure, increased JVD, tachycardia • Tachycardia, hypertension, LV failure • Distended neck veins, muffled heart sounds, hypotension - ANSWER-Distended neck veins Muffled heart sounds Hypotension Tachycardia is an early sign of tamponade. A narrowed pulse pressure occurs, and fluid cannot be ejected from the heart. The muffled heart sounds occur because the fluid in the sac minimized the transmission of sound waves. Which of the following hemodynamic changes will occur with cardiac tamponade? • Increased cardiac output • Stroke volume decrease • Contractility increases • Decreased heart rate - ANSWER-STROKE VOLUME DECREASE Because the heart cannot adequately fill or eject its contents, stroke volume (SV) decreases and causes a decreased cardiac output (CO). Contractility decreases because the muscles cannot stretch and, therefore, cannot contract effectively. If your pt had a cardiac tamponade, which of the following would you expect to see on a CXR? • A dilated superior vena cava • Increased JVD • Narrowed mediastinum • Delineation of the pericardium and epicardium - ANSWER-A DILATED SUPERIOR VENA CAVA The vena cava is dilated because blood couldn't flow into the right atrium. JVD would not be visible on a CXR. The mediastinum would be widened. Delineation of the pericardium or epicardium would not be visible on a CXR. Your pt was admitted for severe dyspnea, dysphagia, palpitations and an intractable cough. On auscultation, you hear a loud S1 and a right sided S3 and S4. This pt probably has? • Mitral insufficiency • Myocarditis • Atrial stenosis • Mitral stenosis - ANSWER-MITRAL STENOSIS These symptoms could be caused by mitral stenosis, an ischemic left ventricle, or failure of a left ventricle. The S3 and S4 sounds suggest both a fluid problem and a pressure problem. Quincke's sign is usually seen in which of the following conditions? • Mitral Stenosis • Endocarditis • Aortic insufficiency • Pericarditis - ANSWER-AORTIC INSUFFICIENCY Quincke's sign is elicited by pressing down on he finger top; a visible pulsation is seen in the nail bed. The sign results from a pulse with a rapid, initial hard pulsation, followed by a sudden collapse as blood flows back through the incompetent valve. In pts with aortic insufficiency, the popliteal BP is often higher than the brachial BP by at least 40 mm HG. This discrepancy between the measurements is known as? • DeMusset's Sign • Hill's Sign • Holmes' Sign • Rochelle's Sign - ANSWER-HILL'S SIGN Hills's sign reflects the rapid rise in pulsation. DeMusset's sign is also found in aortic insufficiency; it consists of the bobbing of the head in time with the forceful pulse. Holmes' and Rochelle's signs are not diagnostic signs. In stable angina, which of the following is true? • A positive treadmill test will indicate CAD • A thallium test (myocardial scintigraphy) will not diagnose LV dysfunction • The treadmill test will miss as many as 20% of cases of single-vessel disease • CK-MB isoenzymes and troponins will not increase - ANSWER-CK-MB ISOENZYMES AND TROPONINS WILL NOT INCREASE A positive treadmill test may not be positive for CAD. LV dysfunction may be diagnosed with a thallium test (myocardial scintigraphy). Treadmill stress tests miss as many as 40% of cases of single-vessel disease. Actions of beta blockers include? • Increased myocardial oxygen demand • Increased heart rate • Increased diastolic filling time • Increased afterload - ANSWER-INCREASED DIASTOLIC FILLING TIME If the inferior wall of the heart is infracted, the leads that will most directly reflect the injury are?