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Hemodynamics

Hemodynamics in the ICU

*Please take the quiz below the lectures to receive credit.

Objectives

Basic monitoring routinely performed in the ICU
Advanced hemodynamic monitoring techniques and their utility

Articles

Using cardiac output monitoring to guide perioperative haemodynamic therapy
Postoperative hemodynamic instability and monitoring

Lectures

Hemodynamics the Introduction

Hemodynamics I

Hemodynamics II

Hemodynamics III

Quiz

Hemodynamics Quiz

Name*
First Last
1. True or False: due to the site from which it is obtained, the SvO2 is usually higher than ScVO2*
- True
- False
2. Of the methods/measurements used in assessing hemodynamics, all of the following are non-invasive except:*
- a. ECG
- b. Venous oxygen saturation (SvO2)
- c. Blood Pressure Cuff
- d. Pulse Oximetry (SpO2)
3. Limitations of pulse oximetry include all of the following except:*
- a. Cannot differentiate other hemoglobin states such as carboxyhemoglobin or methemoglobin
- b. Movement can limit accuracy
- c. It requires an uninjured extremity (trauma)
- d. Changes in blood flow (i.e. hypothermia, vasoconstriction) can affect its ability to get a measurement
4. The most sensitive leads used to monitor for cardiac infarction by telemetry are:*
- a. II, V5
- b. II, aVF
- c. II, III
- d. I, II
5. An arterial line should be zeroed at the level of the:*
- a. Tragus
- b. Catheter insertion site
- c. Umbilicus
- d. Right Atrium
6. All of the following are true concerning a dampened arterial wave form except:*
- a. Differentiated using the square analysis test
- b. Underdamping indicates line failure and necessitates arterial line replacement
- c. The mean arterial pressure will remain unchanged
- d. Overdamping may be caused by kinks, clots, or air bubbles
7. Absolute contraindications of PA catheter placement include all of the following except*
- a. RV endocarditis
- b. Right sided Masses or thrombi
- c. Tricuspid/Pulmonic stenosis
- d. Severe coagulopathy
8. All of the following are true of mixed venous oxygen saturation (SvO2) except:*
- a. It is a marker of O2 utilization
- b. Shown to be beneficial for goal directed therapies in sepsis
- c. Has not been shown to improve outcomes in critically ill patients
- d. It can be obtained from any existing central line
9. All of the following are true concerning measuring the CVP except:*
- a. It is a very sensitive indicator of hypervolemia
- b. It is used to indirectly assess LVEDV
- c. It is affected by positive pressure ventilation
- d. It is incorporated into many goal-directed therapies
10. When using arterial waveform analysis (FloTrac/Vigileo) to calculate cardiac output, all of the following conditions may render its reading inaccurate except*
- a. Positive pressure ventilation
- b. Persistent peripheral vasoconstriction
- c. Used with an IABP in place
- d. Continuous flow ventricular assist devices

Shock Overview

*Please take the quiz below the video to receive credit.

Objectives

Define the different types of shock and pathophysiology associated with each
Describe methods of shock assessment and differentiation
Understand and describe appropriate management strategies for shock

Articles

Circulatory shock
Fluid bolus therapy: Monitoring and predicting fluid responsiveness
Understanding central venous pressure: not a preload index?

Lecture

Quiz

Shock Quiz

Name*
First Last
1. Septic Shock is a type of what general form of shock?*
- a. Cardiogenic
- b. Hypovolemic
- c. Obstructive
- d. Distributive
2. What type of shock is associated with bradycardia?*
- a. Neurogenic shock
- b. Septic shock
- c. Cardiogenic shock
- d. Hemorrhagic shock
3. What product is produced by tissue cells in the presence of hypoxia?*
- a. LDH
- b. Creatine Kinase (CK)
- c. Lactate
- d. C-reactive protein
4. What is the name of the ultrasound protocol designed to differentiate between cardiogenic and non-cardiogenic causes of shock in peri-arrest scenarios?*
- a. FEEL protocol
- b. FAST protocol
- c. FAET protocol
- d. FALL protocol
5. All of the following are methods used to assess volume status except:*
- a. Arterial wave form analysis
- b. CVP measurement
- c. Ultrasound
- d. SvO2
6. Pulse pressure variation (PPV) is used to assess:*
- a. Relative volume responsiveness
- b. Hypovolemia
- c. Effective hypotension
- d. Adequate oxygen delivery
7. Limitations to using arterial wave form analysis to measure SVV or PPV include all of the following except:*
- a. Mechanically ventilated tidal volumes must be greater than 8cc/kg
- b. The patient must be able to follow commands
- c. The patient must be in normal sinus rhythm
- d. The patient must not be breathing spontaneously
8. What value demonstrates better predictability of hypovolemia when compared to PCWP?*
- a. CVP
- b. RVEDI
- c. SvO2
- d. SVV
9. When using ultrasound to assess a patient's volume status, a caval index greater than _______ indicates fluid responsiveness.*
- a. 30%
- b. 40%
- c. 50%
- d. 60%
10. True or False: Oliguria as defined by less than 0.3cc/kg for 3hrs is not a specific indicator of hypovolemia.*
- True
- False

Vasopressors in the OR

*Please take the quiz below the video to receive credit.

Objectives

Understand and describe commonly used vasopressors
Understand and describe commonly used vasodilators
Identify and discuss indications and differences among commonly used drugs

Articles

Vasopressin: Mechanisms of action on the vasculature in health and in septic shock
Vasopressors During Sepsis: Selection and Targets

Lectures

Quiz

Vasopressors in the OR

Name*
First Last
1. True or false, Alpha 2 adrenergic agonists act by increasing arterial tone.*
- True
- False
2. True or false, Beta 1 adrenergic agonists increase contractility and heart rate.*
- True
- False
3. Which of the following receptors does epinephrine NOT act upon?*
- a. Alpha 1
- b. Beta 1
- c. Alpha 2
- d. Beta 2
4. Which of the following medications acts solely on the alpha receptor and has no beta effects?*
- a. Norepinephrine
- b. Phenylephrine
- c. Dopamine
- d. Epinephrine
5. In which of the following situations should norepinephrine be your first vasoactive drug of choice.*
- a. A septic patient whose primary issue is vasodilatation, with presumed normal cardiac function
- b. A hypotensive patient in cardiogenic shock with an EF of 25%
- c. A trauma patient with penetrating wounds, unknown EF, hypotensive in the 60s
- d. None of the above, Norepinephrine should always be your first drug of choice in a hypotensive patient
6. You are working in the TICU and are taking care of a 25yo M with a history of a MVC three days prior. His injuries include right femoral neck fracture as well as TBI. He has an EVD and codman wire in place. You are called to the bedside by his nurse because his CPPs are below goal. His EVD was just transduced and his ICP was 8. His MAP is 55, his HR is 105, temp 37.9, recent TTE appears euvolemic with normal contractility, and most recent blood work reveals a Hct of 27 and lactate of 1.2. What medication would be the most appropriate choice to raise the patients’s MAP and CPP.*
- a. Epinephrine
- b. Norepinephrine
- c. Vasopressin
- d. Phenylephrine
7. True or False, Dopamine acts primarily on the Beta 1 receptors at low doses, and primarily at the alpha 1 receptors at higher doses?*
- True
- False
8. Dobutamine acts on the following receptors?*
- a. Alpha 1 (by decreasing SVR)
- b. Beta 1 (by increasing contractility)
- c. Beta 2 (by decreasing afterload)
- d. Both beta 1 and beta 2 (by increasing contractility and slight decrease in afterload)
9. What is the mechanism of action of Milrinone?*
- a. Alpha 1 and beta 1 agonist
- b. Works with the V1 and V2 receptors
- c. Inhibits cAMP phosphodiesterase
- d. Alpha 1 and alpha 2 agonist
10. True or False, Milrinone increases contractility without direct effect on blood pressure.*
- True
- False
11. Nitroglycerin should be used with caution in neuro patients with high ICPs due to what reason?*
- a. It is a potent arterial dilator
- b. It is a potent venodilator and arterial dilator, causing increased intracranial pressures
- c. It can cause shunting of the blood to the brain
- d. It can interfere with a patients neurological exam
12. Which of the following antihypertensives has the shortest half life, making it an easily titratable drip?*
- a. Nitroglycerin
- b. Labetalol
- c. Diltiazem
- d. Amiodarone
13. Why should calcium channel blockers and beta blockers be used with caution in conjunction with each other?*
- a. Calcium channel blockers may cause or worsen heart block and therefore should be used with caution with beta blockade
- b. Profound hypotension may occur with the use of both calcium channel blockers and beta blockers
- c. The use of calcium channel blockers and beta blockers is contraindicated as it may cause asystole
- d. No caution must be taken when using beta blockers and calcium channel blockers together

Cardiac Arrest & Resuscitation

*Please take the quiz below the video to receive credit.

Objectives

Describe and define the pathophysiology of a cardiovascular arrest.
Formulate the correct management of patient’s experiencing a cardiovascular arrest.
Determine whether appropriate post-resuscitative measures have occurred in a resuscitated cardiovascular arrest patient.

Articles

Vasopressin and Epinephrine vs. Epinephrine Alone in Cardiopulmonary Resuscitation

Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: Propensity score matched Analysis

Lecture

Quiz

Cardiac Arrest

Name*
First Last
1. True or False: A cardiac arrest is defined as the abrupt loss of heart function in a person who may or may not have diagnosed heart disease.*
- True
- False
- Third Choice
2. The LAD feeds which of the following muscle areas?*
- a. The RV-lateral/posterior wall and LV-inferior wall
- b. The LV-lateral/posterior wall
- c. The RV-anterior wall, LV-septum/apex/anterior wall
- d. The RV anterior wall/LV-inferior wall
3. After which rhythm would one initiate lidocaine immediately after ROSC?*
- a. Atrial Fibrillation
- b. VF/pulseless ventricular tachycardia
- c. SVT
- d. Asystole
4. For which rhythm would the provider initiate Amiodarone?*
- a. Pulseless Ventricular tachycardia
- b. Atrial fibrillation with RVR
- c. SVT
- d. Asystole
5. Which is not a reversible cause of PEA arrest?*
- a. Hypovolemia
- b. Tamponade
- c. Hypoglycemia
- d. Tension pneumothorax
- e. None of the above
6. What is the ACLS IV dose of Epinephrine?*
- a. 1 mg every 3-5 minutes
- b. 0.5 mg every 3 minutes
- c. 1 mg every 2 minutes
- d. 2 mg every 3 minutes
7. Which is not a complication of utilizing Hypothermia post-cardiac arrest?*
- a. Hypercoagulable state
- b. Renal insufficiency
- c. Seizures
- d. Relative hypokalemia with metabolic acidosis
8. Which of the following rhythms is a shockable rhythm?*
- a. SVT
- b. Ventricular Fibrillation
- c. Atrial fibrillation
- d. Asystole
9. How frequently should you rotate the compressor while doing CPR?*
- a. Every 10 minutes
- b. Every 5 minutes
- c. Every 2 minutes
- d. Every 7 minutes
10. Which of the following is not in the ACLS adult cardiac arrest algorithm?*
- a. 2 minutes of CPR between pulse checks
- b. Amiodarone
- c. Epinephrine
- d. Vasopressin

EKGs in the Critically Ill

*Please take the quiz below the video to receive credit.

Objectives

Identify and describe life threatening rhythms found on EKG
Discuss non-specific but common EKG findings associated with acute cardio-pulmonary conditions

Articles

ECGs for the emergency physician

Life-Threatening Arrhythmias in the Intensive Care Unit

Lecture

Quiz

*Use the images in this document to answer the questions below.

EKGs

Name*
First Last
1. 61 y/o male with palpitations and lightheadedness exhibits the above on EKG. Identify the rhythm in image 1.*
- a. Ventricular tachycardia
- b. Supraventricular tachycardia
- c. Sinus tachycardia
- d. Atrial fibrillation with rapid ventricular response
2. 33-year-old obese man with sharp chest pain and dyspnea exhibits the following on EKG (see image 2 in pdf) The rhythm is highly suggestive of which of the following:*
- a. Pulmonary embolism
- b. Left bundle branch block
- c. Pericarditis
- d. Infero- lateral wall MI
3. 43-year-old man, with severe palpitations exhibits the following on EKG (see image 3). Identify the rhythm.*
- a. SVT with RBBB
- b. Sinus tachycardia with LBBB
- c. Ventricular tachycardia
- d. Atrial fibrillation with rapid ventricular response
4. 45-year-old man with severe left chest pressure, nausea, and diaphoresis exhibits the following on EKG (see image 4). The rhythm is highly suggestive of which of the following?*
- a. Acute inferior MI
- b. Antero-lateral MI
- c. Changes associated with pulmonary embolism
- d. Changes associated with pericarditis
5. 85-year-old woman presents after a syncopal episode, still reports lightheadedness and exhibits the following on EKG (see image 5). The rhythm is highly suggestive of which of the following?*
- a. First degree AV block
- b. Second degree AV block type 2
- c. Second degree AV block type 1
- d. Third degree AV block
6. 66-year-old man with severe lightheadedness and diaphoresis exhibits the following on EKG (see image 6). Identify the rhythm.*
- a. Atrial fibrillation
- b. Sinus Tachycardia with premature atrial contractions (PACs)
- c. Atrial flutter
- d. Multifocal atrial tachycardia
7. 62-year-old man with renal failure complains of progressive dyspnea and orthopnea after missing his last two hemodialysis sessions exhibits the following on EKG (see image 7). Identify the rhythm.*
- a. First degree AV block with changes consistent with hyperkalemia
- b. First degree AV block with changes consistent with hypokalemia
- c. Second degree AV block type II with changes consistent with hyperkalemia
- d. Second degree AV block type II with changes consistent with hypokalemia
8. 36-year-old woman has had intermittent episodes of palpation and lightheadedness exhibits the following on EKG (see image 8). Identify the rhythm.*
- a. Sinus bradycardia with PVCs
- b. Wolff-Parkinson-White syndrome
- c. Left bundle branch block
- d. Posterior wall infarct
9. 23-year-old woman with sudden abdominal pain and vaginal bleeding exhibits the following on EKG (see image 9). Identify the rhythm.*
- a. Sinus tachycardia
- b. Supraventricular tachycardia
- c. Atrial fibrillation
- d. Ventricular tachycardia
10. 32-year-old M with pleuritic chest pain and dyspnea exhibits the following on EKG (see image 10). The rhythm is highly suggestive of which of the following?*
- a. Acute pericarditis
- b. Infero-lateral infarct
- c. Pulmonary embolism
- d. Anterior wall infarct

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