BKAT Study Questions and Answers 2023

BKAT Study Questions and Answers 2023 What to do first if patient has chest pain. Rest! ECG changes in an acute MI ST elevation in 2 or more contiguous leads. Ischemia d/t full thickness loss of muscle. EMERGENCY. Inferior leads II, III, aVF. RCA occlusion. Septal leads V1 & V2. Anterior leads V1 - V4. LAD lesion. Lateral leads V5, V6, I, and aVL. Circumflex lesion. Cardiac enzymes Troponins, CK-MB, and CK Changes in CK Rise: 3-6 hours Peak: 24 hours Normal: 3-4 days Changes in CK-MB Released after myocardial necrosis. Specific for myocardial damage. Rise: 3-12 hours Peak: 24 hours Normal: 2-3 days Troponin I Protein found in cardiac muscle. High sensitivity. Rise: 3-12 hours Peak: 24 hours Normal: 5-10 days Troponin T Protein found in cardiac muscle. High sensitivity. Rise: 3-12 hours Peak: 12-48 hours Normal: 5-14 days Common conditions that cause a murmur Aortic dissection, aortic regurgitation (both acute & chronic), mitral valve regurgitation (both acute & chronic), mitral valve stenosis Drugs to decrease afterload/SVR/PVR (Arterial Dilators) Nitroprusside, nitroglycerin, amrinone, alpha (Regitine) & Ca channel blockers Drugs to increased afterload/SVR/PVR (Vasopressors) Epinepherine, norepinepherine, dopamine, neosynephrine Drugs to decrease contractility/SVI Beta blockers (atenolol, metoprolol, propranolol, labetolol, esmolol) and Ca channel blockers Drugs to increase contractility/SVI Positive inotropes, dobutamine, dopamine, milrinone, and digoxin Drugs to decrease preload/CVP/PAWP Venous Dilators - Nitroglycerin, nitroprusside, amrinone, alpha & Ca channel blockers Diuretics - Furosemide, bumex, mannitol Drugs to increase preload/CVP/PAWP Volume - Colloid, crystalloids, blood, hetastarch Dysrhythmia control - antirhythmics, pacemaker, AICD Complications when using thrombolytics Allergic reaction, bleeding/hemorrhage, stroke Failure to capture Pacer delivers a stimulus at the appropriate time but no depolarization occurs. No P or QRS wave after pacer spike. Failure to fire/pace No pacer spikes seen Failure to sense Pacemaker does not detects heart's intrinsic activity or interprets noncardiac activity as intrinsic activity. Spikes in inappropriate times. Normal PR 0.12 - 0.20 Normal QRS 0.04-0.10 Normal QT Less than 0.48. Varies by age, HR, and gender. Vasopressors Epinepherine, norepinepherine, dopamine, phenylephrine/neosynephrine, vasopressin/pitressin, milrinone/Primacor, dobutamine/Dobutrex Indication for dopamine/Intropin Acts on SNS to increased HR and BP. Indicated for hypotension, low CO, decreased renal blood flow. Use if patient is bradycardic. Doses of dopamine Low: 0.5-2 mcg/kg/min (dopaminergic) Intermediate: 2-10 mcg/kg/min (beta receptors, increases CO) High: over 10 mcg/kg/min (alpha receptors, vasoconstrict) SE of dopamine Watch volume and starting BP. Use central line. Inactivated by sodium bicarb. Can cause acidosis. SE: ectopic beats, tachycardia, tissue necrosis d/t extravasation Treatment of dopamine extravasation Phentaolmine 5-10 mg and possibly nitropaste to vasodilate Indication for norepinepherine/Levophed Indicated for diastolic hypotension (specifically decreased SVR) and septic shock. Stimulates alpha & beta receptors. Increased contractility, HR, and vasoconstriction. Doses of norepinepherine 2-12 mcg/min. Immediate onset. SE of norepinepherine Replace volume first because it can cause GI and renal hypoperfusion. Have a central line. SE: dizziness, HA, hyperglycemia, myocardial/mesenteric/renal ischemia, tissue necrosis with extravasation. Treatment of norepinepherine, epinepherinem, dobutamine, and Neosynephrine extravasation Phentaolmine 5-10 mg. Indications for epinepherine/Adrenalin Simulates alpha and beta receptors. Used post cardiac surgery for "stunned" myocardium. ACLS protocol. Bronchial relaxation at low doses, increased contractility at high doses. Dosages of epinepherine 2-20 mcg/min. Immediate onset. Irritating to heart, so only good for emergency use. SE of epinepherine SE: myocardial/mesenteric/renal ischemia, tachycardia, hyperglycemia, HA, tissues necrosis with extravasation SE of phenylephrine/Neosynephrine Pure alpha stimulator. Used during C/P bypass, anesthesia induced hypotension, vascular failure in shock. Vasoconstricts arterioles without cardiac effect. Dosages of Neosynephrine 10-100 mcg/min. Immediate onset. SE of Neosynepherine Use central line. Wean this first! SE: Reflex bradycardia, myocardial/mesenteric/renal ischemia, tissue necrosis with extravasation. Indications for vasopressin/Pitressin Antidiuretic hormone used to vasocontric. Endogenous hormone. Vasoconstricts peripheral arterioles & vasodilates coronary, pulmonary, and CNS circulation. Effective for hypotension, shock, decreases needs of other pressors, and Cardiac surgery. Dosages of vasopressin 1-10 units/hr. Long half-life. Not titrated. SE of vasopressin SE: Skin/mesenteric ischemia, bradycardia, decrease UOP & result in hyponatremia, use with caution in neurosurgery patients Indications for dobutamine/Dobutrex Beta I stimulator. Used to increase CO for systolic heart failure, cardiogenic shock, MV regurgitation, post MI, post cardiac surgery, C/P bypass for "stunned" myocardium. Dosages for dobutamine 2-15 mcg/kg/min. SE of dobutamine Less effect on HR than dopamine. Use central line. Check compatibilities. Can be used peripherally during an emergency. SE: ectopic beats, tachycardia, arrhythmias, tissue necrosis with extravasation. Indications for nitroprusside/Nipride Causes peripheral vasodilation by acting on venous and arterial smooth muscle. Decreases BP, SVR, preload, and afterload therefore increasing CO. Used for HTN, CHF, and hypertensive emergency. Dosage of nitroprusside 0.5-0.10 mcg/kg/min. Light sensitive. Start with low dose. SE of nitroprusside Make sure there is adequate volume and the BP is above 90. May incompatibilities (can use with nitro & heparin). Can cause thiocyanate toxicity with higher doses. Monitor for metabolic acidosis. SE: hypotension, HA, nausea, and vomiting. Indications for milrinone/Primacor Positive inotrope with vasoactive activity. Increases CO and decreases SVR. Used in CHF and to increase CO. Dosage of milrinone Bolus (50 mcg/kg over 10 minutes) and then gtt (0.375-0.75 mcg/kg/min). Precipitates with lasix. Longer half-life. Not titrated. SE of milrinone Renal excretion. SE: arrythmias, decreased BP, HA, hypokalemia Indications for nitroglycerin/Nitrostat Direct relaxation of vascular smooth muscle and vasodilation. Used for HTN, angina, CHF, and MI to decrease O2 demands. Dosage of nitroglycerin 5-200 mcg/min. Start low. Immediate response. SE of nitroglycerin Use with caution for patient dependent on preload for CO (inferior wall MI or right sided MI). May see tolerance after 24 hours. SE: Hypotension, reflux tachycardia, HA, flushing, nausea. IV antidysrhythmics Atropine = bradycardia Lidocaine = VT, ventricular irritability Amiodarone = afib, VTACH, Vfib Pronestyl = VTACH, Vfib (can cause torsades) Verapamil = CA channel block, IV push Diltiazem = Ca channel blocker, afib, make sure BP good Adenosine = SLAM IT, SVT, short half-life Indications for a pacemaker Treat sudden cardiac death, EF 35%, sustained VT, refractory HF despite optimal medical management Problems with pacemakers Failure to capture, over sensing, and under sensing Signs and symptoms of cardiac tamponade Rise in filling pressure with decreased CO & hypotension. CVP=PAOP=PAD. Sudden drop in bleeding. Narrowing pulse pressure. Tachycardia, dysrhythmias, decreased ECG voltage. Decreased UOP. Anxiety and restlessness. Low blood pressure and weakness. Chest pain radiating to neck, shoulders, or back. Trouble breathing or taking deep breaths. Rapid breathing. Discomfort that is relieved by sitting or leaning forward. Postoperative care of chest tubes Assess q15 for first few hours to monitor drainage changes. Output to average ~100 cc/hr and should gradually decrease. Average is a total of 1L output. Chest tubes are removed when total drainage is 100 ml for 8 hours. If output 100 ml/hr then order PT, PTT, and platelets. Purpose of Swan (PA) catheter Measure vascular capacity, blood volume, pump effectiveness, and tissue perfusion. Visual of PA catheter waveforms Normal CVP/RAP 1-8 mm Hg Normal PAWP/LVEDP (left ventricular end diastolic pressure) 4-12 mm Hg Normal PAP Systolic: 15-25 mm Hg Diastolic: 6-12 mm Hg If PAWP is low? Hypovolemia If PAWP is elevated? Hypervolemia and indicative of left ventricular failure. Normal CO 4-8 L/min Normal SVO2 60-80% O2 into lungs Describe CVP waveform Three peaks (a, c, v waves) & Two descents (x and y) Describe "a" wave with CVP Represents atrial contraction. Correlates to PR interval. Describe "c" wave with CVP Represents closure of tricuspid valve. Correlates to QRS complex. Describe "v" wave with CVP Represents atrial filling. Correlates to TP interval. How to measure CVP 1) Phlebostatic axis (4th intercostal space & midthoracic line) 2) Print strip. Measure at end expiration. VENTILATED = valley. Regular breathing = peak. 3) Find zpoint at end of QRS. Describe x descent of CVP Atrial relaxation. Ventricular systole. Describe y descent of CVP Tricuspid valve reopening Causes of elevated CVP RV failure, tricuspid stenosis or regurg, pericardial effusion, constrictive pericarditis, superior vena cava obstruction, fluid overload, hyperdynamic circulation, high PEEP setting