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What causes the first (S1) heart sound?
Closure of the mitral and tricuspid valves at the beginning of systole
What causes the second (S2) heart sound?
Closure of the aortic and pulmonic valves (semilunar valves) at the beginning of diastole
An S3 heart sound is an indicator of what condition?
Gallop rhythm; during mid-diastole, most often in the context of CHF
Describe murmur and stethoscope location for mitral stenosis
Characteristic opening snap early in diastole and a rumbling diastolic murmur; chest piece over cardiac apex.
Describe the murmur and stethoscope location for mitral regurgitation
A blowing holosystolic murmur best heard over the cardiac apex radiating into the axilla
Describe the murmur and stethoscope location for aortic stenosis
Systolic murmur, best heard in 2nd R ICS with transmission to the neck
Describe the murmur and stethoscope location for aortic regurgitation
Diastolic murmur, best heard at the L sternal border
How is aortic valvular regurgitation graded?
Angiographically
Grade 1+:  Small contrast enters LV during diastole, cleared during systole
Grade 2+:  LV faintly opacified during diastole, not cleared during systole
Grade 3+:  LV is progressively opacified
Grade 4+:  LV completely opacified during 1st diastole, remains so for several beats
What is the problem if the newborn has a systolic and a diastolic murmur?
PDA; more intense during systole, waxing and waning with each beat (machinery murmur)
What will be heard when evaluating the heart sounds of a patient with CHF?  Where should stethoscope be placed?
S3 gallop; Left-sided with bell at LV apex during expiration, patient L lateral.
Right-sided best heard at L sternal border or just beneath xiphoid, increased with inspiration
What dysrhythmia is commonly observed with mitral valve lesion?
Atrial fibrillation
With atrial flutter, fib or junctional rhythm a portion of LV filling is lost.  What percent of LVEDV is normally contributed by atrial contraction?
25-30%
Define ejection fraction and state the normal range
The ratio of SV (EDV-ESV) to EDV.  EF=SV/EDV
Normal range is 0.6-0.8 or 60-80%
What are the two determinants of cardiac output?
Stroke volume and heart rate; CO=SV x HR
What is stroke index, and the normal value?
SI=SV/BSA; 40-60 ml/beat/m2
Starling's law of the heart relates ventricular filling during diastole to what?
The amount of blood ejected during sytsole; the greater the preload, the greater the quantity of blood pumped into the aorta during systole
Describe the process that causes ventricular myocyte relaxation (lusitropy)?
Intracellular calcium must be reduced back to resting levels.  Calcium is sequestered in the sarcoplasmic reticulum through energy-dependent processes.
Name the organs in the vessel rich group (VRG)
Brain, kidney, liver, lungs, heart, digestive tract, and endocrine tissues
What percentage of CO goes to the liver?
25%
What percentage of CO goes to the heart?
4-5% (225 mL/min)
What percentage of CO goes to the brain?
15%
What percentage of CO goes to the kidneys?
20%
What percentage of CO goes to the lungs?
100%
What percentage of the right heart's cardiac output traverses the bronchial circulation?
0%
What percent of the left heart's output traverses the bronchial circulation?
1-2%
Vessels delivering blood to the bronchial circulation arise from what arteries?
Thoracic aorta and intercostal arteries
Describe where isovolumetric relaxation occurs on the LV pressure-volume loop
From closure of the aortic valve to opening of the mitral valve
Describe where isovolumetric contraction occurs on the LV pressure-volume loop
From closure of the mitral valve to opening of the aortic valve
The release of catecholamines from the adrenal medulla is under the control of the autonomic nervous system.  The neurotransmitter controlling the release is
Acetylcholine
Fibers that synapse with the adrenal medulla are
Preganglionic
How does positive pressure ventilation affect ADH release?
It increases the release of ADH
How do decreased serum osmolality and decreased sodium affect ADH release?
They decrease the release of ADH
ADH production in diabetes insipidus is
Decreased
Sensory innervation to the epiglottis is supplied by the
Internal branch of the superior laryngeal nerve
Where are the baroreceptors located?
The carotid sinuses and aortic arch
How are the baroreceptors stimulated?
Stretching from elevated mean arterial blood pressure
What results from baroreceptor stimulation?
Increased vagal tone = decreased sympathetic tone, reduced inotropy, reduced chronotropy, and reduced SVR
What is the major metabolic end-product of catecholamine metabolism?
Vanillylmandelic acid (VMA)
How does chronic renal failure affect bleeding time?
CRF increases bleeding time secondary to platelet disfunction (decreased adhesion and aggregation)
What are the characteristics of cardiogenic shock?
Increased PAOP, low CI, increased SVR, venous congestion, reflex vasoconstriction, redistribution of blood to heart and lungs
What is the value of normal GFR?
125 mL/min
What are major diagnostic criteria for fat embolism?
Axillary/subconjunctival petechiae, hypoxemia, CNS depression, pulmonary edema
Polyuria s/p transphenoidal resection of a pituitary adenoma, urine sodium (11 mEq/L), serum sodium (145 mEq/L).  What is the condition?  What is the appropriate treatment?
Diabetes insipidus (inadequate ADH); administer DDAVP
Mobitz II heart block
Characterized by constant P-P and R-R intervals prior to the dropped QRS complex.  Acute onset is associated with MI and can rapidly progress to 3rd degree block.  Atropine is usually not effective and pacing is indicated.
What are the hemodynamic signs seen in end stage liver disease?
Low SBP (90-110 mm Hg), low PaO2 (< 60 mm Hg), high pulse rates (90-110 bpm).  CO may range from 6-20 L/min (hyperdynamic state w/attendant low SVR
What are the signs of cyanide intoxication (r/t nitroprusside administration)?
Tachyphylaxis, metabolic acidosis, increased mixed venous oxygen content
Describe the oculocardiac reflex
Consists of trigeminal (V) afferent and vagal (X) efferent pathways ("five and dime reflex").  Traction on extraocular muscles or pressure on periorbital area is the cause.  May elicit bradycardia, ventricular ectopy, V-fib or sinus arrest.
What is the primary management of the oculocardiac reflex?
Notify the surgeon to temporarly stop stimulation
Total lung capacity
5800 mL
Vital capacity
4500 mL
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