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emerg med exam III > cardiac and vascular emergencies > Flashcards

cardiac and vascular emergencies Flashcards

1
Q

ischemic heart disease (aka coronary artery disease) can be broken down into what two categories

A
  • stable angina
  • acute coronary syndrome
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2
Q

acute coronary syndrome can be broken down into what three categories

A
  • STEMI
  • NSTEMI
  • unstable angina
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3
Q

clinical presentation

  • pressure, heaviness, tightness, fullness, or squeezing in the center or left of the chest precipitated by exertion and relieved by rest
A

angina (pectoris)

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4
Q

​the anginal equivalents: exertional dyspnea, nausea, diaphoresis, weakness, palpitations, syndrome are more commonly in what patient population

A
  • elderly
  • diabetic
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5
Q

diagnostic testing for angina

A
  1. 12-lead EKG
  2. stress testing
  3. coronary angiography
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6
Q

pharmacologic stress echocardiogram is performed using what drug

A

dobutamine

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7
Q

indications for pharmacologic stress echo

A
  • unable to exercise
  • inability to achieve target HR during exercise (beta-blocker)
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8
Q

technique of radionuclide myocardial perfusion imaging

A
  1. rest images obtained
  2. exercise or pharmacologic stress induced
  3. radioactive tracer administered under stress conditions
  4. exercise/stress images obtained
  5. perfusion defect will be seen in areas of hypoperfusion
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9
Q

treatment regimen for stable angina

A
  1. nitrates
  2. beta blockers: first line for chronic angina
    1. CCB: no response to nitrates and beta blockers
  3. antiplatelet medication
    1. asa
    2. clopidogrel (plavix)
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10
Q

management of low risk patients with normal EKG

A
  • observation
  • serial cardiac enzymes
  • stress testing and CT coronary angiography, can assist CV risk stratification in ED
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11
Q

Variant Angina (prinzmetal angina, vasospastic angina) typically have what episodes of chest pain

A
  • episodes of angina (5-15 min)
    • usually at rest and often between midnight and early morning
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12
Q

what is diagnostic for Variant Angina (prinzmetal angina, vasospastic angina)

A
  • coronary angiography
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13
Q

treatment of Variant Angina (prinzmetal angina, vasospastic angina)

A
  • nitrates
  • CCB
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14
Q

workup of chest pain in the ED includes

A
  • EKG
  • CXR
  • pulse oximetry
  • labs: CBC, CMP, D-dimer, lipids, BNP, cardiac enzymes (Troponing, CK-MB)
  • echocardiogram
  • angiography
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15
Q

initial management of STEMI

A
  • MONA
    • morphine
    • oxygen
    • nitroglycerin
    • aspirin 325 mg, chewed
  • beta blocker
  • anticoagulation: unfractionated heparin
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16
Q

preferred mechanism for revascularization in STEMI

A
  • PCI: Percutaneous coronary intervention
    • if not available in 120 minutes -> fibrinolytics
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17
Q

what are the absolute contraindications to thrombolytics

A
  • hx of hemorrhagic CVA
  • ischemic CVA in last 3 months
  • presence of a cerebral vascular malformation or intracranial malignancy
  • suspected aortic dissection
  • active bleeding
  • significant closed-head or facial trauma within the preceeding 3 months
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18
Q

what is the gold standard for diagnosing CAD? what interventions can it do

A

coronary angiography

  • interventions:
    • angioplasty
    • stenting
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19
Q

revascularization options

A
  • PCI
  • fibrinolytic therapy: tPA
  • antiplatelet therapy: glycoprotein IIb/IIIa inhibitor
  • CABG
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20
Q

define a NSTEMI

A
  • non-occlusive thrombus
  • ischemia with elevated cardiac enzymes
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21
Q

clinical presentation

  • CP with increasing severity, frequency, duration
  • occurs at rest
  • not relieved with rest and/or nitroglycerin
A

unstable angina

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22
Q

inital managment of NSTEMI/unstable angina

A
  • MONA
    • morphine
    • oxygen
    • nitroglycerin
    • asa 325 mg, chewed
  • beta blocker
  • anticoagulation: unfractionated heparin
  • revascularization (PCI, if needed)
    • no thrombolytics
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23
Q

ask about the use of what before giving nitroglycerin

A
  • sildenafil
  • vardenafil
  • tadalafil
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24
Q

clinical presentation

  • usually occurs soon after MI (first 2-3 days)
  • transient
  • +/- chest discomfort
  • PE: pericardial rub
  • echo: pericardial effusion
A
  • per-infarction pericarditis (PIP)
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25
Q

treatment of per-infarction pericarditis (PIP)

A
  • ASA + colchicine
  • *avoid NSAIDS*
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26
Q

clinical presentation

  • chest pain, tachypnea, dyspnea
  • hypotension, JVD, muffled heart sounds, pulsus paradoxus
A

pericardial tamponade

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27
Q

how is acute mitral regurgitation diagnosed

A
  • TTE: transthoracic echocardiogram
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28
Q

ischemia to papillary muscle post MI can cause

A

acute mitral regurgitation

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29
Q

What is Dressler’s syndrome

A
  • postcardiac injury syndrome
  • develops weeks-months post MI
  • secondary form of pericarditis
30
Q

treatment of Dressler’s syndrome

A
  • NSAIDs
  • corticosteroids or colchicine if refractory
31
Q

clinical presentation

  • fever, cough, dyspnea, orthopnea
  • palatal, conjunctival, or subungual petechiae, splinter hemorrhage, oslers node, janeway lesions, roth spots
A

endocarditis

32
Q

how is endocarditis diagnosed

A
  • blood cultures x 3 (at least an hour apart)
  • echo: identify affected valves
33
Q

cxr: cardiomegaly, cephalization, and kerley b lines are consistent with what

A

heart failure

34
Q

treatment for heart failure

A
  • sublingual nitrates for active cp without hypotension
  • ACE-I
  • directics: furosemide
  • sodium restrictions
35
Q

admission criteria to ICU for heart failure

A
  • pulmonary edema
  • cardiogenic shock
  • concomitant MI or ischemia
36
Q

most common type of cardiomyopathy

A

dilated cardiomyopathy

37
Q

clinical presentation

  • dyspnea
  • PE: S3 gallop, rales, increased jugular venous pressure
  • Cxr: cardiomegaly, pulmonary congestion
A

dilated cardiomyopathy

38
Q

hypertrophic cardiomyopathy has a risk for

A

sudden cardiac death

39
Q

clinical presentation

  • dyspnea, syncope, angina
  • PE: S4 gallop, biphasic carotid pulse
  • Echo, MPI: small left ventricle and diastolic dysfunction
A

hypertrophic cardiomyopathy

40
Q

treatment of hypertrophic cardiomyopathy

A
  • beta blockers or CCB
  • surgical or nonsurgical ablation of the hypertrophic septum
41
Q

clinical presentation

  • decreased exercise tolerance, dyspnea, peripheral edema
  • PE: S3
  • echo: reduced LV function
  • fibrosis or infiltration of ventricular wall
A

restrictive cardiomyopathy

42
Q

treatment for restrictive cardiomyopathy

A
  • diuretics until
  • cardiac transplant
43
Q

hypertensive urgency

A
  • SBP > or = 180; DBP > or = 120
  • no end organ damage
44
Q

hypertensive emergency

A
  • SBP > or = 180; DBP > or = 120
  • acute end organ damage
    • cerebrovascular
    • cardiac
    • renal
45
Q

treatment of hypertensive emergencies

A
  • ICU
  • treat end organ damage, not absolute BP
  • reduce MAP by <20-25% within 1 hour
46
Q

medical management of asymtomatic thoracic aortic aneursym

A
  • aggressive BP control
  • beta blockers
  • serial imaging (CT, MRA at 6 months)
47
Q

when is surgery required for thoracic aortic aneursym

A
  • symptomatic
  • rapid aneurysm expansion
    • growth > 0.5 cm in 6 months
  • > 5.o cm
48
Q

management of asymptomatic abdominal aortic aneursym < 5.5 cm

A
  • observation
  • ultrasound q 6 mo-1yr
49
Q

complications of abdominal aortic aneursym

A
  • rupture
  • aneursym thrombosis
  • thromboembolism
50
Q

when is surgery required for abdominal aortic aneursym

A
  • asymptomatic AAA > 5.5 cm
  • rapidly expanding
    • growth > 0.5 cm in 6 months
  • associated with peripheral arterial aneurysm or PAD
51
Q

clinical presentation

  • “ripping” or “tearing” chest pain radiating to the back
A

thoracic aortic dissection

52
Q

clinical presentation

  • severe back, abdominal, or flank pain + hypotension and shock
A
  • abdominal aortic dissection
53
Q

treatment of acute ascending thoracic aortic dissection

A

cardiac surgical emergency

54
Q

treatment of descending thoracic aortic dissection

A
  • managed medically if hemodynamically stable and without end organ damage
55
Q

imaging used to evaluate for aortic dissection

A
  • CT angiography: hemodynamically stable
  • Multiplanar TEE Transesophageal Echocardiogram: hemodynamically unstable
56
Q

initial management of aortic dissection

A
  • intubation: if hemodynamically unstable or airway compromise
  • ICU
  • morphine
  • reduce SBP to 100-120, HR < 60
    • IV beta blocker
  • CT
57
Q

management of asymptomatic carotid disease

A
  • aspirin + statin
  • consider CEA: Carotid endarterectomy if stenosis > 70%
58
Q

management of symptomatic carotid disease (TIA, stroke)

A
  • Carotid endarterectomy if >70% stenosis
59
Q

where doe DVTs most often occur

A
  • lower extremities and pelvis
60
Q

treatment of DVT

A
  • anticoagulation
    • low molecular weight heparin
    • heparin followed by warfarin
61
Q

risk factors for pulmonary embolism

A
  • virchows triad
    • endothelial damade
    • hypercoagulability
    • stasis of blood flow
62
Q

gold standard diagnostic for Pulmonary embolism

A

pulmonary angiography

63
Q

what EKG pattern is rare but consistent with PE

A
  • S1 Q3 T3
64
Q

hamptoms hump on CXR is associated with

A

pulmonary embolism

65
Q

Westermark sign on CXR is consistent with

A

pulmonary embolism

66
Q

physical exam when assessing for acute limb ischemia needs to include

A
  • neuro exam bilaterally
    • ​assess sensation and strength
    • pulses
      • doppler for PT, DP
      • ankle brachial index (ABI)
        • < 0.4 -> significant ischemia
67
Q

six P’s associated with acute limb ischemia

A
  • Pain
  • Pulselessness
  • Pallor
  • Paresthesias
  • Paralysis
  • Poikilothermy
68
Q

imaging to assess acute limb ischemia

A
  • CTA, MRA
  • threatened limbs require immediate surgical revascularization
69
Q

initial management of acute limb ischemia

A
  • anticoagulation
    • prior to diagnostic imaging
70
Q

define acute mesenteric ischemia

A
  • acute, sudden onset of intestinal hypoperfusion
71
Q

treatment of acute mesenteric ischemia

A
  • systemic anticoagulation and pain management
  • +/- angioplasty with stent
  • +/- exploratory lapartomy (if peritoneal signs)

emerg med exam III (6 decks)

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