Hemodynamics & Cardiovascular Study Notes

Normal Values

• CVP (RA pressure): 2–6 mmHg (5–10 cm H₂O)

• SVR: 900–1200 dynes/sec/cm⁵

• PAWP: 8–12 mmHg

• MAP: 60–80 mmHg

• CO: 4–8 L/min

• CI: 2.8–3.6 L/min/m²

• PAS: 25–30 mmHg

• PAD: 6–12 mmHg

• SvO₂: 70–75%

• PVR: 80–180 dynes/sec/cm⁵

Treatments Based on Hemodynamics

• CVP >8: Diuretics, nitroglycerin, morphine, lisinopril, losartan

• CVP <2: Fluids, blood, blood products

• PAWP >12: Diuretics, nitroprusside (nipride)

• PAWP <8: Fluids, blood, blood products

• SVR >1200: Nitroprusside, nitroglycerin, hydralazine, lisinopril, losartan, IABP

• SVR <900: Phenylephrine, norepinephrine, epinephrine, vasopressin

• PVR >180: Epoprostenol (Flolan)

• EF <40%: Milrinone, dobutamine, digoxin, AICD

• ↑ Contractility: Metoprolol, amlodipine

Key Treatment Algorithms

• CVP >8 & PAWP <12: NTG, nipride, epoprostenol

• MAP <60 & HR >100: Phenylephrine, vasopressin

• MAP <60 & HR <100: Norepinephrine, dopamine

• MAP >80 & HR >100: NTG, nitroprusside, nicardipine, metoprolol

• CO <4 & MAP <60: Epinephrine

• CO <4, MAP <60, HR <60: Epinephrine, dopamine

• CO <4 & MAP >60: Dobutamine, epi, dopamine, milrinone

Receptor Locations

• Alpha-1: Vessels

• Beta-1: Heart

• Beta-2: Lungs

Medication Pearls

• Do NOT use NTG in RV MI/failure

• Check thiocyanate levels with nitroprusside

• Phenylephrine = pure α-1 agonist

• Alpha-1 meds: Phenylephrine, vasopressin

• Beta-1 meds: Epi, norepi, dobutamine, dopamine

• Beta-2 meds: Albuterol, dobutamine (mild-moderate), milrinone

• Inoconstrictors: Norepi, dopamine, epi

• Vasoconstrictors: Phenylephrine, vasopressin

• For HR >100: Metoprolol, amiodarone, diltiazem

• Norepinephrine may cause abdominal pain (splanchnic vasoconstriction)

Lines & Waveforms

• Preload (Left): PAWP

• Preload (Right): CVP

• Afterload (Right): PVR

• Afterload (Left): SVR

• If PA catheter out of place → Notify MD immediately

Line Removal:

• Central line: Supine, HOB flat, hold breath, firm pressure 5–10 min

• Art line: Firm pressure 5–10 min

NG Tube

• Placement check: Chest X-ray

• Normal drainage: Serosanguinous → serous → clear/yellow/green (2–3 days)

• Abnormal drainage: Coffee grounds, dark brown, >500–1000 mL/day → Notify MD

Neuro

• Normal ICP: 0–15 mmHg

• Normal CPP: MAP – ICP

• Goal ICP tx: <20 mmHg, prevent herniation

• Early ↑ICP: HA, change LOC

• Late ↑ICP: Pupil changes, wide pulse pressure, bradycardia, respiratory changes

• Post-neuro position: HOB up, head midline

• CNS decline: HA, fever, vomiting, nuchal rigidity

Renal

• Pulmonary edema in renal failure: HTN, JVD, frothy sputum, hypoxia

  • Tx: Hemodialysis, morphine, NTG, furosemide

• Anemia in renal failure: Epoetin alfa

Cardiac Emergencies

• Tamponade S/S: Muffled heart sounds, equalized pressures, hypotension

  • Tx: Pericardiocentesis

• Stable angina: Fixed stenosis, exertional, T-wave inversion → Rest, NTG

• Unstable angina: Thrombus, severe, ST elevation → Rest, NTG, PCI/CABG

• Variant (Prinzmetal’s): Vasospasm, ST elevation → CCBs

MI

• Women: N/V, fatigue, back/neck/jaw pain

• Men: Crushing chest pain, SOB, diaphoresis

• Pericarditis: Sharp pain, friction rub, ST changes → HOB up, pain mgmt

• MI locations (EKG):

  • Inferior: II, III, aVF

  • Septal: V1, V2

  • Anterior: V2–V4

  • Lateral: I, aVL, V5–V6

  • RV: V3R, V4R

Acute MI Mgmt:

• Cath lab within 90 min (gold standard)

• Thrombolytics (tPA) if no cath lab, within 6h

• Contraindications: Recent surgery, CVA, ICH, caution with HTN/anticoagulants

• Pharm: Morphine, NTG, O₂, ASA, beta blockers, diuretics

Heart Failure:   

      --->  RV HF S/S: 

JVD, edema, ascites, ↑CVP, liver engorgement            -->LV HF S/S: 

Pulmonary edema, rhonchi, dyspnea, ↑PAWP

• First compensatory mechanism: SNS → ↑HR to ↑CO