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Elaina: Emergency > Cardio EM part 1 > Flashcards

Cardio EM part 1 Flashcards

1
Q

for which cardiac conditions is admission essential?

A

MI, unstable angina, PE, aortic dissection, large spontaneous pneumothorax

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2
Q

for which cardiac conditions can you proceed with DX evaluation and RX usually as outpatient?

A

stable angina pectoris, aortic stenosis, pulmonary HTN

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3
Q

this presents with pleuritic like chest pain that worsens with inspiration, coughing, and laying down?

A

pericarditis

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4
Q

most common cause of pericarditis?

A

coxsackie virus

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5
Q

what will you see on EKG of someone with pericarditis?

A

diffuse ST segment elevation in all leads except AVR and V1

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6
Q

what will you hear on auscultation of a patient with pericarditis?

A

friction rub (high-pitched grating murmur through systole and diastole best heard when learning forward)

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7
Q

what complication do we worry about with pericarditis?

A

effusion and tamponade (but less than 5 percent)

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8
Q

how do we treat pericarditis?

A

NSAIDS; will see response in 3-4 hours

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9
Q

what must you be sure to avoid when treating a patient with pericarditis?

A

anticoagulants! they can bleed into their pericardial space and get cardiac tamponade

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10
Q

hyper-coagulability, stasis, and epithelial injury put you at risk for what?

A

PE and DVT

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11
Q

three most common symptoms of PE?

A

tachypnea, dyspnea, pleuritic chest pain

tachycardia also common

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12
Q

what lab should you order as soon as you confirm PE in your patient?

A

PT/INR – need baseline to see baseline, they need to be normal before you anticoagulate

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13
Q

what acid base disorder will your patient with PE have?

A

respiratory alkalosis

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14
Q

which lab test is 97 percent sensitive for PE, but not very specific?

A

plasma D dimer

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15
Q

diagnostic imaging of choice in someone who you suspect has PE?

A

helical (spiral) CT angiography

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16
Q

loaded card… what is the point system for choosing diagnostics for PE?

A

1) clinical SX of DVT: 3 points
2) other DX less likely than DVT: 3 points
3) HR over 100: 1.5 points
4) immobilization/surgery within past 4 weeks: 1.5 points
5) prior DT or PE: 1.5 points
6) hemoptysis: 1 point
7) malignancy (with RX in past 6 mo): 1 point

PE likely if over 4, PE unlikely if less than or equal to 4 points

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17
Q

if PE is unlikely according to your calculation, how should you proceed?

A

get D-dimer

if negative: PE excluded
if positive: proceed to CT

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18
Q

if PE is likely and you get a helical CT but the findings are indeterminate, what should you proceed to?

A

LE ultrasound or pulmonary angiogram

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19
Q

who do we use thrombolytic therapy for in terms of PE?

A

only if patient is dying or very unstable and hasn’t responded to other therapy; don’t like to do it anymore because outcomes aren’t much better

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20
Q

how do we treat PE?

A

fully anticoagulate (heparin for 5-7 days) or LMWH (as effective) for 3-6 months, then warfarin with goal of INR 2-3

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21
Q

deep, visceral, crushing, heavy, squeezing pain at rest that radiates to neck, neck, arm?

A

STEMI

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22
Q

STEMI may often be mistaken for what?

A

indigestion

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23
Q

atypical STEMI presentations are common in which 3 populations?

A

elderly, women, diabetics

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24
Q

which type of MI presents with sympathetic symptoms (such as elevated pulse, increase in temp)?

A

anterior wall MI

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25
Q

which type of MI presents with parasympathetic symptoms (decreased pulse, decreased temp)

A

inferior wall MI

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26
Q

initial ED care for STEMI?

A

1) Morphine for pain
2) Oxygen supplementation
3) NTG sublingual
4) ASA chewed (160-325 mg)

get ECG within minutes

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27
Q

what will ECG of STEMI show?

A

ST elevation in at least 2 adjacent (contiguous) leads

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28
Q

what additional benefit does morphine have with STEMI other than pain control?

A

vasodilator!

but can lead to venous pooling and BP drop – elevate legs and give IV fluids

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29
Q

which drug has been proven to decrease myocardial oxygen demand and reduce the risk of re-infarction?

A

beta blockers

30
Q

acute PCI requires a door to balloon time of what?

A

less than 90 minutes

31
Q

what is the biggest risk of PCI? why do we prefer it over fibrinolysis?

A

biggest risk = bleeding and death

BUT decreases re-occlusion risk vs. fibrinolysis

32
Q

what is the RX of choice if PCI not available in timely fashion for STEMI? how quick do we need to give it?

A

alteplase (t-PA) within 30 minutes of onset of symptoms (includes transport time)

decreases death by up to 50 percent

33
Q

HX of cerebrovascular hemorrhage, prior stroke within 1 hear, marked HTN over 180/110, internal bleeding, recent head trauma or major surgery are all contraindications to what?

A

TPA

34
Q

what is our ultimate goal of how long we want to keep ischemic time to?

A

120 minutes

35
Q

post TPA thrombolysis, what do we RX?

A

1) full anticoagulation with UFH or LMWH
2) ASA long term
3) Prasurgrel/ticagrelor up to 1 year

36
Q

post PCI/stent, what do we RX?

A

1) ASA long term

2) prasurgrel/ticragrelor up to 1 year

37
Q

what is facilitated PCI? when is it indicated? what must you ensure to NOT do?

A

PCI following TPA..improves outcomes

indicated if you can open artery within 120 minutes

do NOT do too early (before TPA has worn off–risk of bleeding to death) – wait 3-6 hours

38
Q

most common cause of aortic dissection?

A

long standing, poorly controlled HTN (repetitive torque to aortic wall)

39
Q

where do type A aortic dissections lie? where do type B lie?

A

A: start in aortic arch proximal to left subclavian artery

B: start in proximal descending aorta beyond subclavian artery

40
Q

how will a patient with aortic dissection present?

A

severe CP often radiating to back

41
Q

why are aortic dissections so dangerous?

A

they can extend out and narrow/occlude vessels such as the coronaries, mesenteric, renal, or iliac arteries

42
Q

what is the most common finding on echo of a patient with aortic dissection?

A

LVH, weak ejection fraction

43
Q

what is the imaging plan for patient who you suspect has an aortic dissection?

A

STAT multiplanar CT

44
Q

what is INITIAL treatment for aortic dissection in the ED?

A

1) lower BP ASAP!
2) beta-blockers lower LV ejection force (initial DOC – IV labetolol or esmolol)
3) give nitro if needed

45
Q

where do we want to keep BP for a patient with an aortic dissection?

A

goal is SBP around 100

46
Q

which type of aortic dissection requires urgent repair? what do we do with the other one?

A

type A = urgent repair

type B = urgent repair if arterial branch occlusion. otherwise, if stable and dissection doesn’t involve branch arteries you can choose surgery with stents or just treat medically to maintain SBP around 100 with annual CT to monitor (if poor surgical candidate)

47
Q

NSTEMI and UA can look the same on EKG, so how do you differentiate?

A

with NSTEMI there are abnormal cardiac markers (CKMB or troponins) that indicate cell necrosis

48
Q

what is the prognosis for UA and NSTEMI if left untreated?

A

UA: risk of developing MI in following days/weeks

NSTEMI: progression to larger MI/death

49
Q

what will we see on EKG of NSTEMI or UA?

A

evidence of ischemia

ST depression and T wave inversion but 50 percent will have normal EKG!

50
Q

what is the criterion for NSTEMI in terms of troponin?

A

at least one value in greater than the 99th percentile of upper reference limit

if normal repeat every 6-8 hours

51
Q

in what chronic disease can false positive troponin levels occur?

A

renal

52
Q

if PE is unremarkable, negative biomarkers, and no ECG changes but you still have high suspicion for NSTEMI, what should you do?

A

continuous monitoring, serial EKG, serial biomarkers q6-8 hours

if above negative, precede to stress test within 24-48 hours if negative, discharge.

53
Q

if there are ongoing ischemia symptoms, ECG changes, or hemodynamic instability in your patient with NSTEMI or UA, what should you do/give?

A

CCU or telemetry admission

1) nitrates
2) oral beta blocker (metoprolol, IV optional); CCB diltiazem if BB contraindicated
3) ASA
4) prasugrel or ticagrelor
5) UFH or LMWH

54
Q

following full anticoagulation and platelet RX for your patient with NSTEMI, UA..what should your follow up be?

A

low grade stress test or cath lab in 2-3 days to see what you’re dealing with

repeat in 6 weeks with high intensity stress test

55
Q

recurrent angina or post-NSTEMI patients should be considered for what?

A

revascularization!

56
Q

patient presents with increasing fatigue, weakness, “fullness” in the chest, and shortness of breath that is getting worse following bout of pericarditis…what do you expect?

A

cardiac tamponade

57
Q

what will you find on PE of a patient with cardiac tamponade?

A

JVD, soft heart sounds, clear lungs, hypotensive

58
Q

what is beck’s triad of tamponade?

A

1) decline in arterial pressure (decreased EF)
2) elevation of systemic venous pressure (elevated JVP)
3) quiet heart

59
Q

what will ECG of tamponade look like?

A

low voltage in limb and precordial leads

60
Q

what will we see in terms of hemodynamics between LV and RV in a patient with cardiac tamponade?

A

elevation and equilibrium of LV and RV diastolic pressures

LA and RA pressure elevated

61
Q

what is the criteria for pulsus paradoxus? who do we see it in?

A

see it in cardiac tamponade

inspiration results in a marked decrease in LV volume resulting in a systolic BP drop of greater than 10 mmHG

normal is 2-4 mmHG

62
Q

treatment of cardiac tamponade?

A

pericardiocentesis; send fluid culture to cytology to evaluate cause (maybe malignancy)

IV fluids to increase preload

63
Q

if your patient is developing recurring tamponade, what may be indicated?

A

pericardectomy (necessary in 25 percent)

64
Q

your obese male who suffers from CHF decided to go to a hotdog BBQ fully equipped with lays and baked beans. he got so drunk he forgot to take his meds. whats he at risk for?

A

acute pulmonary edema

65
Q

how will a patient with acute pulmonary edema present?

A

severe dyspnea, pink frothy sputum, cool extremities, cyanosis, anxious

66
Q

what signs will you note on PE of a patient with acute pulmonary edema?

A

likely elevated JVD, crackles in lungs, tachycardia, S3 gallop reflecting LV dysunfction

67
Q

what lab is beneficial in diagnosing acute pulmonary edema?

A

BNP – made by ventricles when filling pressures are high

68
Q

what labs must you be sure to draw prior to treating your patient with acute pulmonary edema?

A

electrolytes! need to make sure they are okay before prescribing loop diuretics

69
Q

what will we note on chest x-ray of a patient with acute pulmonary edema?

A

vascular redistribution towards apex, interstitial/alveolar edema (kerley b lines), “butterfly” pattern of alveolar edema, atelectasis

70
Q

how do we treat acute pulmonary edema? (4 drugs)

A

1) supplemental O2 to maintain SAO2 over 91
2) morphine venodilator to relieve anxiety and decrease PCW/LA pressure
3) IV diuretics (furosemide acute venodilator and diuretic)
4) nitrates (decreases preload, will improve dyspnea before diuresis)

Elaina: Emergency (6 decks)

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