Dances of the Heart
S.O.B
2014 ACC/AHA Guidelines
2015 ACLS
ERAS
100
QT value in men for diagnosis of Torsades
What is < .45 in men, < .46 in women Or, remember that a QTc of 500 ms (.50 sec) or more is dangerously prolonged.
100
Three Management strategies for pulmonary HTN include :
What is: 1) Oxygen 2) Diuretics 3) Digoxin 4) Anticoagulation 5) Contraception 6) Avoid anemia 7) Dobutamine (alpha 1 agonist) or Milrinone (PDE III inhibitor) >
100
Name of periop morbidity/mortality calculator that gives percentages of: MACE, death, PNA, VTE, ARF, return to OR, unplanned intubation discharge to rehab/nursing home, surgical infection, UTI
What is NSQIP ? National Surgical Quality Improvement Program
100
During CPR a compression depth of at least _____is required in adults. 1. 1 ½ -2 inches 2. 1 ½ inches 3. 2 inches 4. 2 ½ inches
What is A compression depth of at least 2 inches in adults.” The compression depth of at least 2 inches has been established as the best practice for ensuring minimal perfusion during CPR ?
100
What does ERAS stand for?
What is Enhanced recovery after anesthesia
200
2 treatment strategies for Torsades are?
What is : 1) IV magnesium 2) Defibrillation 3) Overdrive pacing
200
These are two specific criteria in order to be diagnosed with Pulmonary HTN?
What is: 1) mPAP >= 25 mmHg 2) PCWP<=15 mmHg?
200
This pt should get a preop EKG: Pt A: 85 y/o DM, OSA for cataract Pt B: 51 y/o HTN, MVP for lipoma excision Pt C: 66 y/o h/o CVA for TKR
What is Pt C; 4.1 The 12-Lead ECG - Preop resting ECG is reasonable for patients with known CAD, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease, except if low-risk surgery. - Preop resting ECG may be considered for asymptomatic patients without known CAD, except for low-risk surgery. - Routine preop resting 12-lead ECG not useful for asymptomatic patients undergoing low-risk procedures.
200
High Quality CPR includes all of the following except: 1. Allowing for complete chest recoil after each compression 2. Minimizing interruptions in chest compressions 3. Ensuring a 15:2 compression to ventilation ratio 4. Avoiding excessive ventilation
What is: (3) Correct compression to ventilation ration is 30:2
200
Three items given preop by Surgery/ Anesthesia are?
What is: 20 ounces Gatorade Alvimopan 12mg PO Celebrex 200-400mg PO Gabapentin 600mg PO Scopolamine patch DVT prophylaxis
300
Why do we correct the QT interval making it a Qtc?
What is: QT interval is heart rate dependent Shortens at fast heart rates (short R-R interval) Lengthens at slow heart rates (long R-R interval
300
This ventilation strategy is most effective in the management of Pulmonary HTN?
What is Low Tidal Volume Ventilation with low PEEP levels may be the ideal strategy, adjusting respiratory rate to prevent hypercarbia
300
Continue or cancel/delay: If cancel delay, what workup: PSTC: 65 y/o for knee replacement, DES placed 8 mo ago on plavix, ASA. Hx: DM, HTN, CAD. BMI = 31. METS> 4. Echo 6 mo ago EF: 58%, Nml valves, all else WNL.
What is delay; Cardiology clearance Elective noncardiac surgery should be delayed 14 days after balloon angioplasty. - Elective noncardiac surgery should optimally be delayed 365 days after DES. - Consensus decision among treating physicians about risks of surgery and antiplatelet therapy. - Elective noncardiac surgery after DES can be considered after 180 days, if the risk of further delay is greater than the risk of ischemia and stent thrombosis. - Elective noncardiac surgery should not be performed within 30 days after BMS, or 12 months after DES if dual antiplatelet therapy will need to be discontinued periop. - Elective noncardiac surgery should not be performed within 14 days of balloon angioplasty if aspirin will need to be discontinued periop.
300
The 2010-2015 ACLS guidelines simplified and streamlined the cardiac arrest algorithm to emphasize the importance of: 1. high quality CPR 2. minimally interrupted CPR 3. early intubation 4. drug therapy 5. both 1 and 2
What is 5. : This new algorithm emphasizes the importance of high-quality, minimally interrupted CPR, which is fundamental to the management of all cardiac arrest rhythms
300
Three items given intra/op by surgery and Anesthesia are?
What is : 1) lidocaine infusion (40mcg/kg/min) 2) Magnesium 2 grams IV 3) Dexamethasone 4-8mg IV 4) Ondansetron 4mg 5) IV Tylenol 1gram
400
Which one of these is Torsades: Picture Daily Double:
What is: A
400
3 echo findings with pulmonary HTN
What is: TR RVE RAE RVH Flattening of IVS Dilated IVC
400
continue or cancel; if continue the workup warranted 59 y.o for ex. lap, bowel perf, BMI 34, CAD, 2 DES 3 yr ago, on plavix, asa, METS> 4.
What is continue to surgery with appropriate monitoring. Urgent procedure = threat to limb or life if not in the OR in 6-24 hours, time for limited clinical evaluation METS> 4 and MACE > 1% Stepwise approach to CAD (known or risk factors for): 1. If emergency -> clinical risk stratification (that may influence periop management) and proceed to surgery with appropriate monitoring. 2. If surgery urgent/elective and ACS -> refer for cardiology eval and mgmt according to GDMT (goal-directed medical therapy) according to UA/NSTEMI and STEMI CPGs (clinical practice guidelines) 3. If risk factors for stable CAD -> estimate periop risk of MACE on the basis of the combined clinical/surgical risk. This can use the ACS NSQIP risk calculator (www.surgicalriskcalculator.com) or incorporate the RCRI. 4. If risk of MACE <1% -> proceed to surgery without further testing. 5. If elevated risk of MACE (>1%), determine functional capacity with an objective measure or scale, such as the DASI (Duke Activity Status Index). If moderate/good/excellent (>= 4 METs) functional capacity, proceed to surgery without further eval. 6. If poor (< 4 METs) or unknown functional capacity -> pharmacological stress testing if it will impact patient decision making or periop care. If unknown functional capacity, exercise stress testing reasonable to perform. If stress test abnormal, consider coronary angiography and revascularization; the patient can then proceed to surgery with GDMT, or consider alternative strategies, such as noninvasive treatment for the indication of surgery, or palliation. If stress test is normal, proceed to surgery according to GDMT. 7. If testing will not impact decision making or care, proceed to surgery according to GDMT or consider alternative strategies, such as noninvasive treatment for the indication of surgery or palliation.
400
When using waveform capnography, what is the desired level of end-tidal CO2 that indicates adequate chest compressions during CPR? 1. >20mm Hg 2. >10 mmHg 3. >5 mmHg 4. between 20-30 mmHg
2. If the PETCO2 is <10 mmHg during CPR, it is reasonable to try and improve the chest compressions and vasopressor therapy.
400
Three items given post/op by surgery and anesthesia are?
What is 1) Acetaminophen 1gram IV Q6hrs 2) Magnesium oxide 400mg PO daily 3) Lr @ 40cc/hr 4) Oxycodone 5mg PO Q 4 hrs(mild) 5) oxycodone 10 mg PO every 4 hours (moderate) 6) oxycodone 15 mg PO q 4 hours(severe) 7) Dilaudid 0.5-1mg IV prn breakthrough 8) Dulcolax tab 5mg PO POD#1 9) Gabapentin 100mg PO TID 10) Tamadol 50mg PO q 4hr
500
5 causes of Torsades include?
What is 1) Drugs that block potassium channels: some antiarrhythmics or antidepressants 2) Genetic abnormalities of the potassium channel 3) Genetic abnormalities of the sodium channel (think Bruguda Syndrome) 4) Class 1A antiarrhythmics 5) Most class III antiarrhythmics 6) Tricyclic antidepressants 7) Some antibiotics: erythromycin, clindamycin, Bactrim 8) Liquid protein diets 9) Hypomagnesemia, hypocalcemia, hypokalemia 10) Mitral valve prolaspe
500
Video Daily Double What 3 classes of drugs is this lady discussing: https://www.youtube.com/watch?v=9a4untSzLzg? 0:33-1:07
What is 1) Nitric Oxide/ C-GMP phosphodiesterase inhibitors (tadalafil)? 2) Endothelin Antagonists 3) Prostacyclin Analogs
500
continue or cancel; if continue the workup warranted PSTC: 71 y/o for lap hemi-colectomy for obstructive lesion. EGD done two days ago shows obtructive lesion colon. H/o Pulm HTN (44mmHg), mod.TR, mod. MR, eF= 45%(6mo ago), METS>4, but SOB at rest. No JVD, Hepatomegaly, peripheral edema.
What is Continue to surgery ; A-line, Edwards Emergent procedure= threat to life or limb if not in OR < 6 hours, no/very limited/minimal clinical evaluation. Urgent procedure = threat to limb or life if not in the OR in 6-24 hours, time for limited clinical evaluation. Time-sensitive procedure (most oncologic procedures) = a delay of >1-6 weeks to allow for an evaluation and significant changes in management will negatively affect outcome. Elective procedure = could be delayed up to 1 year. Low risk procedure = risk of major adverse cardiac event (MACE) or MI of <1%. Elevated risk procedure = risk of MACE > 1%. 2. Clinical Risk Factors: Recommendations 1. Valvular Heart Disease - If patient has at least moderate valvular stenosis or regurg -> preop echo, if no preop echo within 1 year or change in clinical status or physical exam since last evaluation - If patient meets standard indications for valvular intervention (replacement and repair) on the basis of symptoms and severity, valvular intervention before elective non-cardiac surgery will reduce periop risk. - Elevated-risk noncardiac surgery with intraop and postop hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AS/MR , asymptomatic severe AR with normal LVEF. or asymptomatic severe MS if valve morphology is not favorable for perc mitral balloon commissurotomy. 2. Other clinical risk factors - Chronic pulmonary vascular targeted therapy should be continued, unless contraindicated/not tolerated, in patients with PHTN for noncardiac surgery. - Unless the risks of the delay outweigh the potential benefits, preop evaluation by a PHTN specialist before noncardiac surgery can be beneficial, particularly for those with features of increased periop risk 3.2 Stepwise approach to CAD (known or risk factors for): 1. If emergency -> clinical risk stratification (that may influence periop management) and proceed to surgery with appropriate monitoring. 2. If surgery urgent/elective and ACS -> refer for cardiology eval and mgmt according to GDMT (goal-directed medical therapy) according to UA/NSTEMI and STEMI CPGs (clinical practice guidelines) 3. If risk factors for stable CAD -> estimate periop risk of MACE on the basis of the combined clinical/surgical risk. This can use the ACS NSQIP risk calculator (www.surgicalriskcalculator.com) or incorporate the RCRI. 4. If risk of MACE <1% -> proceed to surgery without further testing. 5. If elevated risk of MACE (>1%), determine functional capacity with an objective measure or scale, such as the DASI (Duke Activity Status Index). If moderate/good/excellent (>= 4 METs) functional capacity, proceed to surgery without further eval. 6. If poor (< 4 METs) or unknown functional capacity -> pharmacological stress testing if it will impact patient decision making or periop care. If unknown functional capacity, exercise stress testing reasonable to perform. If stress test abnormal, consider coronary angiography and revascularization; the patient can then proceed to surgery with GDMT, or consider alternative strategies, such as noninvasive treatment for the indication of surgery, or palliation. If stress test is normal, proceed to surgery according to GDMT. 7. If testing will not impact decision making or care, proceed to surgery according to GDMT or consider alternative strategies, such as noninvasive treatment for the indication of surgery or palliation.
500
Select the sequence that is in the correct order for pulseless VT/VF? 1. give 3 stacked shocks, 5 cycles CPR, check rhythm, give 1 shock, 5 cycles CPR, after 2nd shock give 1mg epinephrine IV push 2. give 1 shock, 3 cycles CPR, check rhythm, give 1 shock, 3 cycles CPR, after 2nd shock give 1mg epinephrine IV push 3. give 1 shock, 5 cycles CPR, check rhythm, give 1 shock, 5 cycles CPR, check rhythm after 2nd shock give 1mg epinephrine IV push 4. give 1 shock, check rhythm, 5 cycles CPR, give 1 shock, check rhythm, 5 cycles CPR, after 2nd shock give 1mg epinephrine IV push
What is 2: A shock is always followed by 5 cycles of CPR. Also, there are no longer any stacked shocks given to treat pulseless VT/VF.
500
Specific SVV on Edwards to stay below; and if above volume of crystalloid infused(in cc/kg/hr)?
SVV less than 13% if > than 13% , administer LR to total volume of 8cc/kg/hr
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