Hemodynamics #3

Question 0

Law of LaPlace

Answer 0

Tension is directly related to diameter, inversely related to the thickness of the container.

Increased tension: increased O2 demand
Decreased tension: decreased O2 demand

**primary determinant of O2 consumption, followed by contractility.

Question 1

Dilated Cardiomyopathy

Answer 1

• Systolic failure: fails to clear or evacuate ventricles. No issues w/ diastolic filling.
• Heart is stretched, muscle tissue thin, increased tension.
• Law of LaPlace
• secondary or volume overload (not pressure)
• CHF, status post AMI

Question 2

Treatment for dilated cardiomyopathies

Answer 2

Cardiac glycosides*, inotropes (dopamine / dobutamine**) & diuretics

• Digitalis
• • decrease in after load w/ vasodilation desired.

Question 3

Digitalis mechanism

Answer 3

• poisons Na/K pump
• heart retains Na
• Antiporter channel forced to secrete Na out
• as Na is forced out, Ca is introduced
• Ca enhances work ability of cardiac cells

Question 4

Hypertrophic Cardiomyopathy

Answer 4

• Diastolic Failure
• muscle has become thick and large
• muscle built on inside, not outside
• decreased intraventricular space
• great squeeze, limited diastolic filling.
• preload becomes critical
• secondary to pressure overload (HTN) not volume.

Question 5

Hypertrophic Cardiomyopathy Tx

Answer 5

1. Fluid to increase preload
2. Increase diastolic filling time
   - beta blockers (decrease HR=longer ventricular fill time.
   - Ca Channel blockers
   - Amiodarone (primarily blocks K)

Question 6

IHSS define and how to recognize

Answer 6

Idiopathic Hypertrophic Subaortic Stenosis

• Hypertrophic Cardiomyopathy
• Systolic murmur at level w aortic valve (2nd intercostal space, R border of manubrium)

Question 7

Restrictive Cardiomyopathy

Answer 7

• Systolic failure
• heart looks relatively normal
• muscle thickened, fibrotic, stiff
• hypodynamic heart, hypoplastic
• Trasmural ischemic tissue fibrosis
• no movement or ejection

Question 8

Restrictive Cardiomyopathy Treatment

Answer 8

Diuretics, anti-coagulation*, and cardiac glycosides**.

• Fluid resuscitate with caution, as fluid cannot be cleared.
• stagnant blood flow increases clot formation.
• *supercharges muscle that is functioning

Question 9

Primary vs secondary hypertrophic disease

Answer 9

Primary: heart was first problem, desease characteristics are secondary to heart
-AMI, pulmonary edema

Secondary: heart disease is secondary to another problem
-HTN

Question 10

Multi valvular disease suggests what illness was suffered?

Answer 10

Rheumatic fever

• Autoimmune disorder triggered by strep a
• bulbous lesions develop on leaflet cusp edges
• scarring and fusion develop
• stenosis and regurgitation follow

Question 11

Where do you hear the aortic heart tone?

Answer 11

2nd intercostal space, just R of Sternum

Question 12

Where do you hear the pulmonic heart tone?

Answer 12

2nd intercostal space, just L of Sternum

Question 13

Where do you hear the tricuspid heart tone?

Answer 13

4th intercostal space, just L of sternum

Question 14

Where do you hear the mitral heart tone?

Answer 14

5th intercostal space, mid-clavicular line
Apex or heart
Point of maximal impulse

Question 15

Systolic murmur

Answer 15

Lub murmur dub… Lub murmur dub

Question 16

Diastolic murmur

Answer 16

Lubb dub murmur… Lubb dub murmur

Question 17

Aortic stenosis

Answer 17

Aortic valve won’t open
Aortic valve is open during systole
-systolic murmur

Question 18

Aortic regurgitation

Answer 18

Aortic valve incompetent

• aortic valve closes during diastole to prevent blood from backing up into heart.
• diastolic murmur
• back pressure into the LV, LA, lungs… Pulmonary congestion, heart overloaded, stretching of heart muscles.

Question 19

Mitral stenosis

Answer 19

Mitral valve won’t open smoothly

• mitral valve opens during diastole to allow the ventricles to fill
• diastolic murmur

Question 20

Mitral regurgitation

Answer 20

• mitral valve is incompetent and leaks
• mitral valve closes during Systole to prevent blood from entering LA during LV contraction.
• systolic murmur
• blood will back in to the LA, lungs resulting in pulmonary congestion

Question 21

Pulmonary stenosis

Answer 21

Pulmonary valve won’t open smoothly

• pulmonary valve is open during systole to allow blood into the lungs
• systolic murmur

Question 22

VSD murmur

Answer 22

Ventriculoseptal defect

• hole between R and L ventricles
• L to R shunt
• overloads the lungs
• predominately systolic murmur
• loud murmur equals small defect
• silent murmur equals large defect
• auscultated primarily over apex of heart

Question 23

RN/WT murmur

Answer 23

• Auscultated over all valvular areas
• biphasic murmur (lub murmur dub murmur)
• predominantly found in south eastern Caucasian population
• depressed socioeconomical status frequently living in mobile homes

Question 24

Type one aortic dissection

Answer 24

Ascending aorta and extending distally beyond Aortic Arch - worst type worse prognosis - involves whole aorta - can cause heart attacks. Bulging in aorta impedes aortic valve and vessels coming off the beginning of the aorta / coronary arteries - can cause back pressure cardiac overload and pulmonary congestion

Question 25

Type 2 aortic dissection

Answer 25

Limited to ascending aorta - jet erosions and Marfan's syndrome - can proceed to coronary arteries =AMI - can proceed to carotid arteries = CVA - pain and hemodynamic change equals hypertension

Question 26

Type 3 aortic Dissection

Answer 26

Dissection distal to the origin of the left subclavian artery and extends distally to abdominal aorta. -Best prognosis

Question 27

Aortic dissection diagnosis

Answer 27

Widened mediastinum on x-ray with diffuse infiltrates

Question 28

Aortic dissection treatment

Answer 28

Lower systolic blood pressure to 100 -110 mmHG with vasodilators. -managed BP and HR at same time -don't want a sudden change in hemodynamics -aggressive pain relief (Pain=sympathetic nervous system= catecholamines. MS can complicate BP, fentanyl is appropriate)

Question 29

Vasodilators to be used with aortic dissection's

Answer 29

Nipride (nitro press) - easily titrated - start minimal, titrate small incriments - q 2-5 min - immediate response Beta blockers (slow HR & decrease ejection fraction) - esmolol burns off relatively quickly - metropolol longer lasting (caution)

Question 30

HTN treatment

Answer 30

Dial pressure to their normal within 30 to 60 minutes. Not immediately. - dropping pressure to fast risks CVA or AMI - chronic- diuretics & ace inhibitors