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Flashcards in CARDIO PACKET 4 TX Deck (12)
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1
Q

Cardiogenic shock/hypovolemic shock

Based on prompt diagnosis and accurate appraisal of inciting conditions
Initial management
• Basic life support: _____, _______, airways
• Main entail airway _______ and mechanical ventilation
• Ventilatory failure should be anticipated in patients with severe _______
• Unresponsive or minimally responsive patients should have glucose checked
o Low glucose; 1 ampule of 50% dextrose IV
• IV access and fluid resuscitation
• Cardiac monitoring and assessment of hemodynamic parameters such as blood pressure and heart rate
• Arterial line for continuous blood pressure measurement
• Foley catheter for urine output measurements
• Cardiac monitoring can detect myocardial ischemia or malignant arrhythmias
o Treated by ACLS protocols

Central Venous Pressure
• Consideration of placement of a central venous catheter for infusion of ____ and medications and for hemodynamic pressure measurements
• CVP greater than __ mm Hg suggests volume overload, cardiac failure, tamponade, or pulmonary hypertension
• May place Pulmonary artery catheters to measure the pulmonary artery pressure
• A CVP of less than _ mm Hg suggests hypovolemia
• Treatment is directed at maintaining a DVP of 8-12 mm Hg, a mean arterial pressure of 65 mm Hg or higher a cardiac index of 2-4 L/min/m2 and a ScvO2 greater than 70%

Volume Replacement
• Initial management of shock
• Hemorrhagic shock is treated with immediate efforts to achieve hemostasis and rapid infusions of blood substitutes such as type specific or type O negative packed red blood cells (PRBCs) or whole blood
• Hypovolemic Shock secondary to dehydration is managed with rapid boluses of _______ (0.9% saline or lactated Ringer solution) usually in 1 liter increments
• Cardiogenic Shock requires_____ fluid challenges usually in increments of 250 ml

Early Goal directed therapy
• Early treatment before the development of organ failure results in improved survival and patients who respond well to initial efforts demonstrate a survival advantage over nonresponders.

Medications
• After adequate fluid resuscitation
• Choice of vasoactive therapy depends on the presumed etiology of shock as well as cardiac output Continued hypotension with evidence of high cardiac output after adequate volume resuscitations
o Vasopressor support is needed to improve vasomotor tone
• Evidence of low cardiac output with high filling pressures
• Inotropic support is needed to improve contractility

Vasodilatory shock
• Vasoconstriction is needed to maintain adequate perfusion pressure
• Alpha adrenergic catecholamine agonists are generally used
• Norepinephrine is both alpha adrenergic and beta adrenergic agonist
o Preferentially increases mean arterial pressure over CO
o Initial dose 1-2 mcg/min as IV infusion titrated to maintain the mean arterial blood pressure at 65 mm Hg or higher; maintenance dose is 2-4 mcg/min IV
• Epinephrine
o Used in refractory shock
o Severe shock and during acute resuscitation
o 1 mcg/min as continuous IV infusion and titrated to hemodynamic response
Vasoactive therapy:
• Dopamine

Cardiogenic Shock
• Insufficient evidence to recommend a specific vasopressor to use in cardiogenic shock
• Expert opinion suggests that either _______ or _______ be used as a first line agent
o Dobutamine is predominantly a beta-adrenergic agonist, and increases contractility and decreases afterload
o Used for patients with low cardiac output and high PCWP (pulmonary capillary wedge pressure)
o Or if there are signs of hypoperfusion despite adequate volume resuscitation and adequate mean arterial pressure
o Initial dose is .1-.5 mcg/kg/min as continuous IV infusion and titrated to hemodynamic effect
o Tachyphylaxis (acute and sudden decrease in response) can occur after 48 hours secondary to the down regulation of beta adrenergic receptors
o Amrinone and milrinone are phosphodiesterase inhibitors
 Can be substituted for dobutamine
 Vasodilation is a side effect

A

circulation, breathing
intubation
metabolic acidosis

fluids
18
5

isotonic crystalloid
smaller

norepinephrine, dopamine

2
Q

aortic aneurysms

AAA:
Surgical repair is indicated for AAA >___ cm in diameter or any size AAA with rapid growth

Elective repair:
• AAAs > 5.5 cm in diameter or rapid expansion (> .5 cm in 6 months)
• Symptoms of pain and tenderness indicate impending rupture: ____ repair

Thoracic aortic aneurysm
• >_cm: consider repair
• Descending thoracic aorta: often endovascular grafting
• Proximal aortic arch or ascending aorta: difficult; open procedure
• 4-10% rate of paraplegia following repair of thoracic aneurysm endovascularly

A

5.5
urgent

6

3
Q

aortic dissection

Medical
• Aggressive measures to lower__ immediately
• Bring down to 100-120 systolic
• First line therapy: _______ IV (labetolol) or esmolol
• Nitroprusside IV is used in patients where Beta blockade does not adequately bring down BP
• Goal heart rate: 60-70 bpm

Surgical:
• Urgent surgical intervention is required for all Type _ dissections
• Transfer facilities if necessary
• Type _: early thoracic stent repair
• Untreated Type A’s: 90% mortality at 3 months
• Uncomplicated Type B’s: with BP control may have long term survival without surgery: aneurysms develop: need yearly CT scans

A

BP
beta blockers
A
B

4
Q

lymphedema

  • Due to the progressive nature, very difficult to treat!
  • Treat any ______ causes
  • Refer to specialty wound care center if possible
  • _______ legs as much as possible
  • Graduated elastic ________ stockings or lymphedema wraps
  • Pneumatic pressure devices
  • Meticulous skin care to avoid cellulitis
  • Once infection starts, treat with abx to cover Staph and Strep (______ 500 mg QID x 7-10 days)
A

underlying
elevate
compression
Cephalexin

5
Q

lymphagitis

  • Heat to affected area
  • Elevation
  • Immobilization
  • Analagesia
  • Antibiotic therapy to cover Staph and Strep infections
  • _______ 500 mg QID x 7-10 days
  • ______ 750 mg BID x 7-10 days
  • If MRSA suspected use Bactrim (TMP-SX) 2 tabs DS BID x 7-10 days
  • Meticulous wound care to the site of bacterial entry
  • May need debridement
  • Prognosis – with prompt and appropriate care infection generally resolves quickly. Delays in care can result in tissue loss, sepsis
  • All patients with lymphangitis should be admitted to hospital to start abx and monitor responsiveness to therapy
A

cephalexin

augmentin

6
Q

acute arterial occlusion

the 5 P’s

  1. _______: constant and aggravated by movement
  2. _____: occurs initally, followed by cyanosis
  3. __________: with cold limb
  4. _______: caused by anoxia to peripheral nerves
  5. ______: necrosis of muscles
•	Time critical factor
•	Consult vascular surgery!!
•	Unless that is a contraindication, immediate anticoagulation with heparin should be started to prevent further propagation of the clot
o	\_\_\_\_\_\_: IV bolus 5,000- 10,000 U
o	1000 U/h to 1500 U/h
o	•TT: 1.5-2 times normal range
  • Patient remains heparinized until etiology established
  • If cardiac emboli the source: long term management with oral anticoagulants (warfarin) needed.
  • Will still need operative intervention
  • Endovascular
  • Surgical intervention
A
pain
pallor
pulselessness
parathesias
paralysis

heparin

7
Q

superficial venous thrombophlebitis

•	Mainly symptomatic tx
o	Analgesics 
o	Warm compresses 
•	If septic thrombophlebitis 
o	Remove any \_\_\_\_\_\_
o	IV antibiotics (vancomycin PLUS ceftriaxone)
A

lines/catheters

8
Q

DVT

• Anticoagulant: first line
o LMWH, ______
• _____: for recurrent DVT/PE despite adequate anticoagulation or stable patients in whom anticoagulation is contraindicated

A

warfarin

IVC filter

9
Q

varicose veins
• Non-surgical management – elastic graduated ______ stockings
• Stockings worn daily
• Elevate legs at night
• Sclerotherapy – sclerosing agent injected into the veins
• Induces fibrosis and obliteration into the target vein
Surgical
• ________ (laser or radiofrequency)
• Vein stripping

A

compression

thermal ablation

10
Q

chronic arterial insufficiency

PAD treatment
1:
•	Cardiovascular risk factor reduction
•	Smoking cessation
•	Lipid and blood pressure management
•	Weight loss
•	Antiplatelet therapy
2: structured exercise program

• All symptomatic patients should be on antiplatelet agent
o ______ 81 mg daily
• High dose statin – ________(Lipitor) 80 mg daily
• Trial of Cilostazol (Pletal) 100 mg BID improves walking distance in patients with disabling claudication
• A program of daily walking to point of claudication followed by rest period should be repeated several times daily
o Enhances development of collateral circulation and improves circulation
o Patients should try to “walk through their claudication” a little more each day
Other treatments:
• Vascular reconstruction or angioplasty and stenting : indicated for patients with debilitating claudication, rest pain or evidence of severe occlusion
• Arterial grafts (prosthetic or saphenous vein) used to bypass occluded vessel

A

aspirin

atorvastatin

11
Q

buerger disease

  • Stop ________!!
  • Usually halts the disease
  • Since the distal arterial tree is occluded, patient cannot be revascularized
  • If patient will not stop smoking, ______ of both upper and lower extremities is the eventual outcome
A

smoking

amputation

12
Q

giant cell arteritis

_______ 60 mg qd x one month
•After one month, trial of steroid tape
•Monitor ESR and patient sxs on steroid taper

A

prednisone