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EMERGENCY MED > Cardio > Flashcards

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1
Q

EMERGENCY DDx for Chest Pain - 7

A

PAPA PEP!

  1. PE
  2. ACS (STEMMI vs Unstable angina–>NSTEMMI) - [CHEEST CCC] w/u
  3. PTX/tension PTX
  4. Aortic dissection
  5. Pericarditis/myocarditis
  6. Esophageal rupture
  7. Peptic ulcer rupture

Unstable angina progresses to an NSTEMMI

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2
Q

What is Levine sign

A

pt puts clenched fist to chest to describe MI

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3
Q

What are historical features that point to ACS/MI - 8

A
  1. Onset: gradual
  2. Quality: Crushing, Squeezing, Tight, Pressure
  3. Region
  4. Radiation: Substernal/Radiates
  5. Timing: Pain between 30min - 3hours
  6. AssociatedSx: Diaphoresis, Apprehension, NV
  7. Previous: Yes
  8. Fam hx of 1st degree male relative with ACS at ≤ 50 yo
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4
Q

Common Causes of Chest Pain are usually CRGMP

Describe the Cardiac Causes -6

A

CRGMP

  1. ACS (Unstable,Stable,Prinzmetal Variant, MI)
  2. Cocaine - DONT GIVE BETA BLOCKERS
  3. Pericarditis
  4. Aortic Dissection
  5. Valvular
  6. [Non-ischemic Cardiomyopathy]

CRGMP = Cardiac/Respiratory/GI/Msk/Psych

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5
Q

Common Causes of Chest Pain are usually CRGMP

Describe the Respiratory Causes -5

A

CRGMP

  1. PE
  2. PNA
  3. Pleurisy
  4. PTX
  5. Pulm HTN/Cor Pulmonale

CRGMP = Cardiac/Respiratory/GI/Msk/Psych

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6
Q

Common Causes of Chest Pain are usually CRGMP

Describe the Gastrointestinal Causes -5

A

CRGMP

  1. GERD
  2. PUD
  3. Esophageal (dysmotility, inflammation, rupture)
  4. Pancreatitis
  5. Biliary (cholecystitis, cholangiits)

CRGMP = Cardiac/Respiratory/GI/Msk/Psych

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7
Q

Common Causes of Chest Pain are usually CRGMP

Describe the Musculoskeletal Causes -4

A

CRGMP

  1. Costochondritis
  2. Rib Fracture
  3. Muscular strain
  4. Herpes Zoster

CRGMP = Cardiac/Respiratory/GI/Msk/Psych

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8
Q

Common Causes of Chest Pain are usually CRGMP

Describe the Psychogenic Causes -2

A

CRGMP

  1. Panic DO
  2. Hyperventilation

CRGMP = Cardiac/Respiratory/GI/Msk/Psych

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9
Q

Which demographics tend to present with ACS/MI in an atypical way? - 3 ; What sx would you expect with them?-5

A

Women / Elderly / Diabetics

  1. only SOB
  2. only NV
  3. Palpitations
  4. syncope
  5. complete cardiac arrest!

chest pain may or may not be present in these populations

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10
Q

When is Angina classified as Unstable -3

A

when chest pain is…

  1. > 20 min or ⬆︎in frequency
  2. New
  3. occurs at rest
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11
Q

When it Nitroglycerin contraindicated? - 2

A
  1. Pt took Phosphodiesterase inhibitors within last 24 hours
  2. Inferior wall MI
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12
Q

What therapies are used to treat ACS?-7 ; how do these help with ACS?

use CHEEST CCC for ACS workup

A

Pts with ACS Need OBAMAA!

  1. NTG 0.4mg q5min x ≤3 = VasoDilates Veins and Coronary Arteries
  2. Oxygen = Minimizes ischemia
  3. Beta Blockers = ⬇︎ HR –> ⬇︎O2 demand AND⬇︎ Arrhythmia risk
  4. [ASA325 and Heparin] = limits thrombosis
  5. Morphine = Pain
  6. ACEk2 inhibitors within 24 hrs= ⬇︎ [L Ventricle Dilation/Remodeling]
  7. AtorvaSTATIN - comes later

Careful: ASA and Beta blockers can –> asthma exacerbation

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13
Q

Contraindications to giving beta blockers - 9

A
  1. HR < 60
  2. Systolic BP < 100
  3. 2nd or 3rd degree heart block
  4. LV dysfunction
  5. COPD severe
  6. Asthma severe
  7. peripheral hypOperfusion
  8. PR > 240
  9. MI secondary to Cocaine
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14
Q

How long does it take Myoglobin cardiac biomarker to

Rise?

Peak?

Return to Baseline?

A
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15
Q

How long does it take Troponin cardiac biomarker to

Rise?

Peak?

Return to Baseline?

A

Troponin iiiii is the most sensitive

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16
Q

How long does it take Creatine Kinase cardiac biomarker to

Rise?

Peak?

Return to Baseline?

A
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17
Q

[Atrial Fibrillation] is the most common tachyarrhythmia. It is often precipitated by what 4 things?

A

“Smh, SAME Afib as before!”

  1. Acute Systemic Illness (Hyperthyroid / HF / HTN)
  2. Sympathetic Tone INC (Hyperthyroid/CHF/Exercise)
  3. EtOH in excess
  4. Mitral Stenosis
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18
Q

What dose of Beta Blockers should be given for ACS?

A

Pts with ACS Need OBAMAA!

Metoprolol 5mg q5min x ≤3 =(with goal of) 60bpm

Careful: ASA and Beta blockers can –> asthma exacerbation

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19
Q

What dose of Morphine should be given for ACS?

A

Pts with ACS Need OBAMAA!

Morphine IV 2-10mg q5-15min

Careful: ASA and Beta blockers can –> asthma exacerbation

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20
Q

What dose of Nitroglycerin should be given to pts with ACS?

A

Pts with ACS Need OBAMAA!

NTG 0.4mg q5min x ≤3

Careful: ASA and Beta blockers can –> asthma exacerbation

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21
Q

Describe the system used to diagnose and assess for DVT

A

Wells Criteria!

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22
Q

List the contraindications to using Thrombolytics for STEMMI ACS - 6

A
  1. Intracranial hemorrhage hx
  2. Aortic dissection
  3. Active bleeding
  4. Closed head or facial trauma within preceding 3 mo
  5. Brain CA
  6. AVM
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23
Q

What is the TIMI Risk Score for STEMI used for? ; What are the components? - 9

A
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24
Q

Reperfusion therapy is given for STEMI within __ hours of chest pain onset. What are the 2 options?

A

12

  1. PCI preferred if within 90 minutes and if CardioShock is present! -otherwise use Thrombolytics
  2. Thrombolytics (“__plase”)
    * PCI = PerCutaneous Intervention*
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25
What is the TIMI Risk Score for Unstable Angina/NSTEMI used for? ; What are the components? - 7
Assess % probability a pt will die within 14 days from MI *one point each* 1. \> 65 yo 2. ≥3 risk factors (Male, Male relatives with MI\<50 yo, smoker, HTN, DM, HLD) 3. needed ASA within last 7 days 4. ≥2 anginal events within last day 5. STEMI on EKG 6. Elevated biomarkers 7. Coronary artery stenosis \> 50%
26
TIMI stands for \_\_\_\_\_\_. For either of the TIMI (Unstable/NSTEMI vs STEMI) how do the stratifications help to make an ED final disposition?
**T**hrombolysis **I**n **M**yocardial **I**nfarction **≥5 = HIGH RISK = HOSPITAL ADMISSION** 3-4 = intermediate risk = observation unit 0-2 low risk = discharge home NEVER USE THIS CRITERIA TO SEND PT HOME. ONLY TO ADMIT. USE HEART CRITERIA TO SEND HOME
27
What is a Prolonged QT in Men?
\> 4**3**0 ms ## Footnote *Prolonged QT and HOCM cause sudden death in youth*
28
What is a Prolonged QT in Women?
\> 4**5**0 ms ## Footnote *Prolonged QT and HOCM cause sudden death in youth*
29
List the main causes of Prolonged QT - 6
**QT WIDTh** 1. **QT** syndromes (Jervell and LangeNielsen, Romano-Ward) 2. **W**olff Parkinson White 3. **I**nfarct 4. **D**rugs - image 5. **T**orsades 6. **h**ypO-KCM (K+, Ca+, or Mg+)
30
Why is Prolonged QT so dangerous?
Predisposes to paroxysmal episodes of VTach and Torsades de pointes R on T
31
Tx for Torsade de Pointes R on T
Mg sulfate IV
32
Sinus Bradycardia is HR \< ___ and is caused by what things?-6
**O**ne **INCCH** 1. **O**vermedication (BBlockers, CBlockers, Digoxin, Cholinergics) 2. **I**nferior wall MI (leads 2, 3 aVF) - resolves within 2 days 3. **N**ormal variant (athletes) 4. **C**arotid sinus response (hypOthermia, hypOxemia, hypersensitive) 5. **C**ushings syndrome (HBO) 6. **H**ypOthyroidism
33
Sinus Bradycardia is HR \< \_\_\_ What is the mngmt for Emergency Sinus Bradycardia?-3
**O**ne **INCCH** \< 60 bpm Atropine IV 0.5-1mg --\> Epi & TransQ pacing
34
Most common causes of Tachycardia - 7
1. Dehydration/hypOvolemia 2. Fever 3. Anemia 4. Anxiety 5. Sepsis 6. Drugs OD 7. Hypermetabolism (hyperthyroidism) ## Footnote *Tx = correct underlying problem*
35
What 2 conditions is Multifocal Atrial Tachycardia associated with?
1. Theophylline use 2. COPD
36
What's the most common dysrhythmia in peds?
SVT ## Footnote *narrow QRS with **regular rhythm** but rate \> 150bpm*
37
How do you manage SVT? - 3 ## Footnote *Regular Narrow QRS with rate \> 150 bpm*
1. Immediate 50J of synchronized cardioversion if HDUS, CHF or ACS 2. Vagal maneuvers (carotid massage,cold water head immersion,valsalva) --\> Adenosine if refractory 3. Diltiazem, Verapamil or BBlcoker to control rate ## Footnote *HDUS = HemoDynamically UnStable*
38
What dose of Adenosine should be given for SVT if Vagal maneuvers don't work? ## Footnote *Regular Narrow QRS with rate \> 150 bpm*
[6mg **rapid IV push** f/b 20cc flush] x ≤3 but with 12mg after first time
39
What dose of Diltiazem or Verapamil should be given for SVT to control rate? ## Footnote *Regular Narrow QRS with rate \> 150 bpm*
Diltiazem = 0.25 mg/kg IV over 2 min OR Verapamil = 0.15 mg/kg IV over 1 min
40
What are the features of Wolf Parkinson White syndrome? -3
Wolf Blitzer **D**rives **W**ith **S**tyle 1. **D**elta wave QRS upslurring 2. **W**idened QRS \> 120 ms 3. **S**hortened PR interval \< 200 ms etx = accessory electrical pathway between the atria and vt enables early ventricular activation --\> SVT and cardiogenic shock
41
Which meds are given to cardiovert Wolf Parkinson White syndrome? - 5
Wolf Blitzer **D**rives **W**ith **S**tyle 1. Amiodarone 2. Sotalol 3. Flecainide 4. Procainamide 5. Propafenone *Meds that preferentially block **AV** conduction (ABCD = Adenosine, BBlckrs, CBlckrs, Digoxin) are contraindicated in WPW!*
42
What are the causes of paradoxical splitting? - 3 ## Footnote *S2 splitting during **Expiration** and not inspiration*
1. HOCM 2. Aortic Stenosis 3. LBBB
43
Which 2 bedside maneuvers **⬆︎** **Intensity** of the HOCM mumur?
"***Val*** [***Stood Up****]* to Hulk HOCM, the MVP, which _⬆︎_ his anxiety" Valsalva [Standing Up] (both ⬇︎ Preload **AND** ⬇︎ Afterload)
44
Duke Criteria for diagnosing Infective Endocarditis - 2
1. 3/3 positive blood cx with first and last drawn ≥ 1 hour apart 2. Echocardiogram positive for IE ## Footnote *substitution for #1 = 2 positive blood cx taken ≥12 hrs apart*
45
Name the manifestations of Bacterial Endocarditis (7)
"Bacteria **FROM JANE**" **F**ever [**R**etinal Roth Spots - *Immunologic phenomena*] [**O**sler "Ouch" Nodes- *Immunologic phenomena*] [**M**umur that's new] [**J**aneway lesions on palms/sole] **A**nemia [**N**ailbed Subungal _Splinter_ Hemorrhages] - shown in image [**E**mboli from valvular vegetations] *also common to have Pleuritic chest pain*
46
Tx for Bacterial Endocarditis (7)
"Bacteria **FROM JANE**" PCN G IV
47
CHF exacerbation is AKA ____ ; Mngmt for this? - 8
Acute Decompensated Heart Failure 1. O2 via face mask 2. Furosemide 40-80mg IV (takes 30 min and last 6 hrs) 3. ASA325 until ACS is r/o 4. Morphine IV 4mg 5. NTG 6. Milrinone **if refractory** 7. Dobutamine **if refractory** 8. Dopamine **if refractory and need arterial pressure ⬆︎**
48
Describe **Pulsus Paradoxus**
⬇︎ [Systolic BP] by more than 10 **during inspiration** "Pulsus for **CAPOT**"
49
3 Common signs of **CONSTRICTIVE Pericarditis**
1. Pericardial Knock= **Sharp** sound heard in early diastole 2. Kussmaul Sign= Paradoxic **[⬆︎ JVP during inspiration]** since *constricted* R Vt can not accomdate the ⬆︎ in blood 3. Pulsus Paradoxus
50
*Clinical* Manifestation of Cardiac Tamponade (3)
"**H**eavy **B**leeding in **P**ericardialSpace * [**B**eck Triad: hypOtension / JVD / Muffled Heart Sounds] * [**H**R ⬆︎ but CO ⬇︎] * **P**ulsus Paradoxus (Pulsus for CAPOT)
51
What conditions cause Pulsus Paradoxus - 5
"Pulsus for **CAPOT**" 1. **C**roup 2. **A**sthma 3. **P**ericarditis 4. **O**bstructive sleep apnea 5. **T**amponade
52
EKG manifestation for Acute Fibrinous Pericarditis-2
**DIFFUSE** ST elevations + sometimes PR depressions ## Footnote *Pericarditis gave **HIM A UTTI***
53
DDx for T-wave inversion - 5
1. MI 2. Myocarditis 3. Myocardial Contusion 4. *OLD* Pericarditis 5. Digoxin OD
54
**Pericarditis** causes-8
"Pericarditis gave **HIM** **A** **UTTI**" - **I**nfection-Viruses (Coxsackie/ echovirus/adenovirus) - **A**cute MI - **I**mmune (Dressler vs SLE vs RA) - [**HMLB** CA] - (Lung/Breast/Hodgkin's/Mesothelioma) - **T**rauma - **T**B - **M**ediastinal Radiation - **U**remia (BUN \> 60) * always make sure these pts dont have ACS*
55
Electrical alternans on EKG is a result of \_\_\_\_\_
Pericardial effusion
56
DDx for Dyspnea on Exertion - 3
1. CHF 2. Aortic stenosis 3. Mitral stenosis
57
Aortic **Stenosis** Clinical features - 5
\*) [Pulsus parvus et tardus]= weak pulses with delayed peak \*) **SAD**: [**S**yncope / **A**ngina / (**D**yspnea on exertion)] \*) [S4 Atrial Kick] *crescendo descrescendo mumur at base, radiating to carotids*
58
Which Murmur? ## Footnote (*Auscultation Site is attached*) B: Maneuvers that INC (2)
**Mitral Regurgitation** *[Holosystolic High-Pitched Blowing Murmur] w/radiation to axilla* "*MR*. **Hand** me a **Squat**" B: INC with... 1) Hand Grip 2) Squatting
59
**M**itral **V**alve **P**rolapse Murmur
"He was _MVP_...OF COURSE he had a **Mid Clique** to hang with" [Late Systolic Crescendo Murmur + **MidSystolic Click**] @ Apex
61
What 3 maneuvers **INCREASE** intensity of **Aortic Regurgitation**
"*AR* your **Hands** & **Breath** [**Leaning Forward**] ? * with **Hand** Grip * when **B****reath** is held after exhalation * with Patient **leaning forward**
62
Best indicator for *_severity_* of valve Regurgitation?
Presence of an **additional S3** (*indicates Vt Dilitation in addition to regurgitaiton*)
63
**Aortic Regurgitation** Mumur
[**Early Diastolic Descrescendo Murmur**-*High Pitched Blowing noise*] auscultated @ [L Sternal 2nd/3rd ICS]
65
Head bobbing with each heart beat or Head pounding is c/w \_\_\_\_\_\_
Aortic Regurgitation ## Footnote *Head bobbing with each heart beat = de Musset sign and is sign of widened pulse pressure*
66
DDx for "Bounding pulses" - 2
1. Sepsis 2. Aortic Regurgitation
67
Which Murmur? ## Footnote (*Auscultation Site is attached*) B: Maneuvers that INC (2)
**Mitral Regurgitation** *[Holosystolic High-Pitched Blowing Murmur]* "*MR*. **Hand** me a **Squat**" B: INC with... 1) Hand Grip 2) Squatting
68
etx for Abdominal Aortic Aneurysm
Atherosclerosis and smoking damages elastin fibers in tunica media --\> thins the tunica media --\> HTN causes aneurysm
69
Imaging modalities for Aortic Dissection-3
1. **TEE**-unstable or renal CTX 2. [Spiral CT Angio] - Stable vitals 3. [MRI-*NonEmergency*] ## Footnote *TEE is great because it's used in renal pts*
70
Acute MI and Aortic Dissection can present similarly What are the major differences? - 3
1. AD will have **HIGH BLOOD PRESSURE** (since this was likely the cause) 2. AD may have other focal neuro deficits (Horner's if SUP cervical sympathetic ganglion is, Hoarse voice if recurrent laryngeal is affected) 3. AD will have a ≥20 mmHg discrepancy between UE and LE --\> cold pulseless extremities
71
What is Beck's triad consist of? ; What does it indicate?
Becky's **H**ead **M**ade **J**oy 1. **H**ypOtension 2. **M**uffled heart sounds 3. **J**VD Cardiac Tamponade which can --\> Pulseless Electrical Activity!
72
Transplant pt comes into the ED with c/o chest pain What are signs & symptoms of acute rejection in transplant pts? - 3
1. Dysrhythmias 2. atypical Fatigue 3. Exertion intolerance ## Footnote *these pts should receive Methylprednisolone 1gm IV STAT*
73
**Compartment Syndrome/Peripheral arterial occlusion is one of the serious s/s of limb threatening injury!** What are its features? - 6
The 6 **P**'s! 1. **P**OOP (*Pain Out Of Proportion*) 2. [**P**aresthesia - EARLY finding] 3. [**P**ulselessness - LATE finding] 4. **P**allor 5. **P**oikilothermia *(inability to regulate body temp)* 6. **P**aralysis
74
Describe [Hypertensive Urgency]
**ONLY** HTN ≥ 180/110
75
Describe [Malignant HTN Emergency] - 2
[Hypertensive Urgency (BP ≥180/110)] + End Organ Damage *End Organ Damage: Papilledema/Retinal Hemorrhages, cerebral edema, pulmonary edema, Aortic dissection, AKI, LV failure*
76
How do you manage HTN urgency or Malignant HTN Emergency] ? - 2
USE IV MEDS! 1st: ⬇︎MAP up to 25% within 1 hour 2nd: After #1, cont ⬇︎ with goal of 160/110 within 2-6 hours USE IV MEDS!
77
Which meds are best for stabilizing HTN urgency/Malignant HTN emergency? - 6
1. **LABETALOL** 2. **NICARDIPINE** 3. Hydralazine 4. Esmolol 5. Nitroprusside 6. Fenoldopam (a2 R agonist)
80
R**R**AIB MC What are the 3 questions for assessig heart Rhythm?
1. P waves present? 2. What is the relationship between P and QRS? 3. Is the rhythm regular or irregular? ## Footnote *small box = 40 ms*
81
Name the causes of Atrial Fibrillation - 9
**H**eavy **PIRAATES** 1. **H**TN 2. **P**ulmonary disease (COPD, PE, OSA) 3. **I**schemia coronary 4. **R**heumatic heart disease - mitral stenosis (get echo) 5. **A**nemia 6. **A**trial myxoma 7. **T**hyrotoxicosis 8. **E**thanol 9. **S**epsis *These can precipitate any type of SVT (including aFib)*
82
How is an acute Mi diagnosed?
Must meet ≥2 out of 3 for *emergency setting* but catherization is ultimate dx 1. *Clinical hx* 2. *EKG changes (get serial if you initially see no changes!)* 3. *Cardiac Enzymes* 4. Cardiac Cath
83
What is the workup for suspected ACS - 9
**CHEEST CCC** 1. **C**ardiac Cath ultimately (consider this first if STEMMI on EKG) 2. **H** & P with HEART score 3. **E**KG within 10 min of arrival - serial 4. **E**cho on admission (looking for wall abnormalities) 5. **S**tress test on admission 6. **T**roponin iii - serial 7. **C**BC (looking for anemia) 8. **C**MP (may affect tx regimen) 9. **C**XR (looking for pulm edema or other causes of cp)
84
HEART score (and also TIMI) is used to risk stratify pts with suspected ACS What is the HEART criteria? ; What is the interpretation for it?
use **CHEEST CCC** for ACS workup
85
Tx options for Thromboembolism - 4
1. Heparin if DVT or PE 2. Enoxaparin **if only DVT** 3. IVC filter if pt has CA, already on PO anticoag or ctd 4. Thrombolytic for massive iLiofemoral thrombosis

EMERGENCY MED (12 decks)

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