Cardiovascular Flashcards
(132 cards)
1
Q
Most common cause of aortic aneurysm is: ______.
A
Atherosclerosis
*caused by smoking!
Other causes: HLD, HTN, connective tissue d/o, male
2
Q
S&S of aortic aneurysm include:
A
- Older male, >60y
- Severe abdominal or back pain with syncope or HTN
- Tender, pulsatile abdominal mass
3
Q
What is the workup for a suspected aortic aneurysm?
A
US!!–> initial test of choice to determine presence, size, and extent (also used to monitor for progression in size).
- CT scan: test of choice for thoracic aneurysms (good for planning surgery for AAA)
- Angiography is gold standard! (often used before surgery)
4
Q
An AAA that is > ___cm has an increased risk of rupture
A
5cm
5
Q
What is the management of AAA?
A
- Surgical repair if >5.5cm in diameter or if >0.5cm expansion in 6 months
- Beta blockers can reduce shearing forces
6
Q
____ is the most important predisposing factor for aortic dissection.
A
HTN
7
Q
Aortic dissections are most common in ____ (age range), _____ (males/females).
A
-50-60y males
8
Q
Aortic dissection is a tear in the ____ (layer of aorta).
A
Tunica intima (inner most followed by media and adventitia).
9
Q
What are the S&S of an aortic dissection?
A
Abrupt onset, unrelenting, tearing “knife like,” ripping, chest/upper back pain, +/- syncope, diaphoresis, weakness, nausea
10
Q
What do you find on PE for a patient with aortic dissection?
A
- Decreased peripheral pulses
- Variation in pulse >20mmHg between rt and left arm
- Ascending dissection will have acute, new onset aortic regurg
11
Q
How is an aortic dissection diagnosed?
A
CT w/ contrast!!!
- Angiography is gold standard
- CXR widened mediastinum
12
Q
How is an aortic dissection managed?
A
- Surgical management- done in ACUTE PROXIMAL (DeBakey I and II) or ACUTE DISTAL with complications (Type III).
- Medical management- in DESCENDING if no complications exist (DeBakey III).
* 1st line= Esmolol and Labetalol
13
Q
What are the primary RFs/causes of DVT?
A
Age, obesity, long distance travel, multiparity, IBD, Lupus
14
Q
What are the S&S of DVT?
A
Unilateral swelling/edema of affected extremity; >3cm most specific symptom.
-Homan’s sign: pain in calf with dorsiflexion
15
Q
How is a DVT worked up?
A
Venous Duplex US
-D-dimer: a negative test can r/o DVT in low risk pts, cannot confirm dx
16
Q
How is DVT treated/managed?
A
*Perioperative DVT prevention: early, frequent ambulation, leg exercise, compression hose
**Treatment: Anticoagulation- Enoxaparin/Lovenox (Low molecular weight heparin) or Unfractionated heparin followed by warfarin
***Major cause of pulmonary embolism :(
17
Q
What are S&S of Peripheral Arterial Disease?
A
Intermittent claudication!–> pain in LE brought on by exercise and relieved w/ rest.
-Advanced dz with ABI < 0.40
18
Q
What are the 6 P’s of acute arterial embolism?
A
Paresthesias, pain, pallor, paralysis, pulselessness, poikilothermia (inability to regulate core body temperature)
19
Q
What are signs of PAD?
A
-Decreased/absent pulses, +/- bruits, decreased cap refill, atrophic skin changes, shiny skin, hair loss, pale on elevation, dependent rubor, LATERAL malleolar ulcers!
20
Q
Diagnosing PAD…
A
ABI–> simple, quick, noninvasive. POSITIVE PAD if ABI <0.90 (0.50= severe), nml ABI= 1.0-1.2
-Arteriography is gold standard
21
Q
How is PAD managed?
A
- Platelet inhibitors- Cilostazol mainstay, ASA, Clopidogrel
- Revascularization- PTA, bypass grafts fem-pop bypass, endarterectomy
- Supportive- foot care, exercise
- Acute Arterial Occlusion- heparin for acute embolism
- Amputation- if severe or gangrene occurs
22
Q
_____ veins are often culprits of varicose veins.
A
Superficial saphenous veins
23
Q
Increased estrogen: OCPs, pregnancy, increased stress on legs, prolonged standing, and obesity are all RFs for _____.
A
Varicose veins
24
Q
What are the clinical manifestations of varicose veins?
A
- Dilated, tortuous veins
- Dull ache, pressure sensation worsened with prolonged standing and relieved with elevation
- Venous stasis ulcers
25
How are varicose veins managed?
Conservative: leg elevation, compression stockings, avoid prolonged standing
-Sclerotherapy, radiofrequency/laser ablation & ambulatory phlebectomy commonly used.
26
With peripheral arterial disease (PAD) leg pain is better when legs are _____ (elevated/dependent) and pain improves with ______ (movement/rest).
Dependent; rest
*Pain is WORSE with walking, elevation of leg, cold
27
Redness of the leg with dependency is known as ______ and is associated with _____.
Dependent rubor; PAD
*Cyanotic leg with elevation
28
Leg ulcers on the _______ are common with PAD.
Lateral malleolus
29
What are some skin findings associated with PAD?
Atrophic skin changes, thin shiny skin, loss of hair, muscle atrophy, pallor, thick nails. Livedo reticularis (mottled apperance).
* Decreased pulses and temperature usually cool
* *Minimal to no edema
30
With peripheral venous disease leg pain is worse with ______ (elevation/dependency).
Dependency, standing, and prolonged sitting make it worse :(
31
Peripheral venous disease improves with what activities?
Walking and elevating the leg
32
Cyanotic leg with dependence is associated with _____ (PAD/PVD).
PVD
33
Leg ulcers located on the ______ are common with PVD.
Medial malleolus, uneven ulcer margins
34
What are some skin findings associated with PVD?
Stasis dermatitis, eczematous rash, thickening of skin, brownish pigmentation
* Pulses and temperature usually normal
* *Prominent edema is common!
35
Claudication is associated with ______. Symptoms include:
PAD
- pain with exercising
- intermittent pain
- pain at rest (as condition worsens)
- discolored skin or ulcerations
36
How is claudication/PAD diagnosed?
Pulses, ABI, Doppler US (to monitor blood flow to the area), MRI/CT (to see if vessels are narrowed with plaque).
37
What are some causes of difficulty breathing after surgery?
Airway blockage, atelectasis and lung infection, blood clots, heart failure, blood loss, PTX
38
Dyspnea is chronic when it occurs over a 4-8 week period and acute when it develops over hours-days.
FYI
39
Most causes of cardiac-related dyspnea include:
1. Cardiac diseases- acute ischemia, systolic dysfunction, valvular disorders, pericardial disease
2. Anemia
3. Deconditioning
40
Dyspnea symptoms and the diseases with which they correlate:
1. Substernal chest pain--> cardiac ischemia
2. Fever, cough, sputum--> respiratory infections
3. Wheezing--> acute bronchospasm
FYI
41
Exertional dyspnea and PND are both associated with heart failure and _____ is more specific.
PND
*Asthma also associated with exertional dyspnea and PND
42
The 5 most common causes of chronic dyspnea are:
1. Asthma
2. COPD
3. Interstitial lung disease
4. Myocardial dysfunction
5. Obesity/deconditioning
43
Specific tests ordered with dyspnea complaint:
- Complete blood count (to exclude anemia): The degree of dyspnea associated with anemia may depend on the rapidity of blood loss and the degree of exertion that the patient undertakes.
- Glucose, blood urea nitrogen, creatinine, electrolytes.
- Thyroid stimulating hormone (TSH).
- Spirometry pre and post inhaled bronchodilator OR full pulmonary function tests (PFTs) if the clinical evaluation does not suggest asthma or COPD.
- Pulse oximetry during ambulation at a normal pace over approximately 200 meters and/or up two to three flights of stairs.
- Chest radiograph.
- Electrocardiogram.
- Plasma BNP or NT-pro BNP
44
What are the 4 major categories for syncopy?
1. Reflex syncope
2. Orthostatic syncope
3. Cardiac arrhythmias
4. Structural cardiopulmonary disease
*Must RULE OUT: seizures, sleep disturbances, accidental falls, some psychiatric conditions (conversion d/o)
45
Prodromal symptoms of syncope include:
●Lightheadedness
●A feeling of being warm or cold
●Sweating
●Palpitations
●Nausea or non-specific abdominal discomfort
●Visual "blurring" occasionally proceeding to temporary darkening or "white-out" of vision
●Diminution of hearing and/or occurrence of unusual sounds (particularly a "whooshing" noise)
●Pallor reported by onlookers
46
Evaluation of syncope if structural heart disease status is uncertain should include a ______.
Transthoracic echocardiogram
47
Acute arterial occlusion is often due to:
- Acute thrombosis of an atheroslerotic artery
- Dissection of artery
- Direct trauma to artery
- Embolus from proximal source lodging into more distal vessel
48
The majority of arterial emboli that travel to the extremities originate in the _____.
Heart (LE affected more than UE).
49
Common places for thromboemboli to lodge include:
The common femoral, common iliac, and popliteal artery bifurcations are frequent locations
50
Sources of emboli from the heart include:
- Atrial thrombus formation due to atrial fibrillation
- Left ventricular thrombus formation following myocardial infarction
- Left ventricular dysfunction, and debris from prosthetic valves and infected cardiac valves (septic emboli).
51
Diagnosis of arterial embolism/thrombosis:
1. Noninvasive options- Duplex US, CT angiography, MRA
| 2. Catheter-based arteriography (dx and treatment!)
52
The classic physical signs of acute limb ischemia in a patient without underlying occlusive vascular disease are the six Ps...
```
Pain
Pallor
Pulselessness
Poikilothermia
Paresthesia
Paralysis
```
53
A third heart sound (S3) in young individuals/athletes is normal. In older patients it indicates _____.
CHF
*KENTUCKY SOUND
54
The third heart sound is caused by a sudden deceleration of blood flow into the ______ from the _____. In the anatomy tab you will see a thin-walled, dilated left ventricle with generalized decreased vigor of contraction.
LV from the LA
55
The fourth heart sound is produced by an increase in stiffness of the left ventricle due to scar tissue formation. This may be a manifestation of ______.
Coronary heart disease
56
A fourth heart sound can also be caused by a greatly thickened left ventricular wall such as with essential hypertension or aortic stenosis. This is shown in the anatomy tab.
TENNESSEE SOUND
57
The most useful importance of S3 is in detecting left-sided heart failure, especially in the early stages when other signs may be normal.
Usually after 40y
58
When S4 is loud it is usually a sign of a failing ____.
Left ventricle
59
Loss of _____ can be the earliest sign of compartment syndrome.
2 point discrimination
60
Which beta-adrenergic blocking agent has cardioselectivity for primarily blocking beta-1 receptors?
Metoprolol
61
A 55-year-old male presents complaining of episodic substernal chest pain that occurs especially during strenuous exercise. Suspecting coronary artery disease (CAD), an exercise stress test is ordered. The test is considered to be abnormal if which of the following occurs?
A 2 mm ST-segment depression is suggestive of cardiac ischemia and is considered to be an abnormal finding
62
The treatment of choice for a patient with WPW (Wolff-Parkinson-White Syndrome) who has recurrent episodes of supraventricular tachycardia is what?
Catheter ablation of bypass tracts
63
What are the indications for a CABG?
Class I indications for CABG from the American College of Cardiology (ACC) and the American Heart Association (AHA) are as follows
-Over 50% left main coronary artery stenosis
-Over 70% stenosis of the proximal left anterior descending (LAD) and proximal circumflex arteries
- Three-vessel disease in asymptomatic patients or those with mild or stable angina
- Three-vessel disease with proximal LAD stenosis in patients with poor left ventricular (LV) function
- One- or two-Vessel disease and a large area of viable myocardium in high-risk area in patients with stable angina
-Over 70% proximal LAD stenosis with either an ejection fraction (EF) below 50% or demonstrable ischemia on noninvasive testing
64
Some studies have found that in patients undergoing noncardiac surgery, perioperative aspirin increases bleeding risk but does not improve cardiovascular or mortality outcomes.
Really depends on patient, doctor, and surgery though
65
Most selective COX-2 inhibitors (celecoxib) and nonselective NSAIDs appear to have negative cardiovascular effects.
Should often be discontinued before surgery
66
Generally, NSAIDs should be stopped ___ day(s) before surgery. Ibuprofen should be stopped ___ day (s) before.
3; 1
67
Pre-surgical cardiac testing guidelines (loose)
1. Patients undergoing high-risk surgical procedures or those at intermediate risk should be considered for non-invasive testing for further risk stratification
2. Patients at high risk should be considered for angiography
3. Patients at low risk should receive no further testing
68
______ (medication class) before surgery can decrease rate of MI, especially given to those at intermediate and high-risk.
Beta blockers
69
Amoxicillin is a common antibiotic to prevent _____ in patients with a history of rheumatic heart disease.
Endocarditis
70
Functional residual capacity (FRC) decreases by:
_____% in lower abdominal operations
_____% in upper abdominal operations
_____% in thoracotomy/lung resection
- 10-15%
- 30%
- 35%
71
Closing volume affects postoperative pulmonary complications. This is the volume at which the flow from the dependent portion of the lungs stops during expiration because of airway closure.
Factors that promote increased CV:
- advanced age
- tobacco use
- fluid overload
- bronchospasm
- presence of airway secretions
72
Lung expansion maneuvers are the mainstay of postoperative prevention of complications and include deep breathing exercises and...
INCENTIVE SPIROMETRY
73
Which hormones increase in the operative period?
Catecholamines, growth hormone, glucagon, ACTH, and cortisol
*This causes HYPERGLYCEMIA in the postoperative patient
74
Usually give ____ (fraction) of the normal dose of injectable insulin the morning of surgery.
1/2
75
In diabetic patient you should give continuous infusion of _____ (IV fluid).
5% dextrose to provide 10 grams of glucose per hour
76
About Adrenal Insufficiency (Addisons)...
Prolonged use of steroids for inflammatory d/o (asthma, RA, IBD) can cause suppression of the hypothalamic release of corticotropin-releasing hormone and the pituitary release of ACTH. This leads to a decrease in the adrenal production of cortisol.
77
______ (medication) can reduce, but not eliminate, the risk of adrenal suppression.
Hydrocortisone (10mg/hr)
78
Fever < ____ is common after surgery.
38.5C (101.3F)
79
Fever associated cytokines are:
IL-1, IL-6, TNF-alpha, IFN-gamma
80
Cytokines in bloodstream act on hypothalamic endothelium--> stimulates production of ____ & ____. This raises the hypothalamic set-point which results in heat conservation & increased heat production.
PGE2 & cAMP
*Get rigors
81
In general, early post-op fever is NOT infectious w/ 1 critical exception:
```
Necrotizing fasciitis (soft tissue infection)
*Also consider malignant hyperthermia and anastomotic leak!!
```
82
What are the 5 W's of postoperative fever?
1. Wind- POD#1-3
2. Water- POD#3
3. Wound- POD#5
4. Walking- POD#7
5. Wonder-drug/What did we do?- Any time
83
Atelectasis occurs in the most dependent parts of the lung in 90% of patients who are anesthetized.
RFs include:
Painful abdominal or thoracic incision, smoking, pulmonary dz (asthma, CF), obesity, respiratory muscle weakness
*Increases risk of PNA and causes fever!
84
To differentiate PNA from atelectasis look for...
Sputum production, elevated WBC, and temp curve that progresses upward
*Atelectasis will usually be bilateral! PNA often presents with a unilateral infiltrate
85
Most common treatment for a wound infection (POD#5) is:
Open it up, release pus, allow tissue to heal from the inside out and "fill in"
86
What is Virchow's triad for DVT/PE (POD#7)?
Stasis, vessel damage, hypercoaguability
87
Necrotizing infection often presents within first 48hrs and kills rapidly. Common agents are:
Clostridium perfringens, Group A B-hemolytic streptococcus
88
Treatment of necrotizing infection includes:
Resuscitation, Pen G, surgical debridement
89
For a subacute/delayed fever (after 5 days post-op)--> infectious etiology is more likely
Remember Wound infection= 40%, UTI = 29%, PNA= 12%
* Also think- C. diff, line sepsis, bacteremia, intra-abdominal abscess
* *Weeks out- endocarditis, infected prostheses
90
Factors that increase the risk of wound infection:
malnutrition, advanced age, immunosuppressive drugs, prolonged hospitalization, recent abx, obesity, catheters, poor tissue perfusion, steroids, radiation
91
Prophylactic abx are given about ____ (length of time) before the operation and discontinued after ____ (length of time).
30-60mins
48-72hrs
92
KOH, silver, or Giemsa stains done to identify _____.
Fungal hyphae or spores
93
Mycobacteria can be identified using the _______ (test).
Ziehl-Neelson
94
If wound infection persists > 48 hours after abx administration then suspect abscess formation and treat by:
Opening and draining the wound
95
What are the 4 classes of wounds?
1. Clean- breast bx, inguinal hernia repair. Usually STAPH. Treat with 1st generation Ceph, may not need prophylaxis.
2. Clean, Contaminated- GI, GU, gyn organs entered, no gross contamination. Cephalosporins used- 1st generation for elective procedures. 2nd or 3rd generation for chole w/ acute cholecystitis and gastric & proximal small bowel surgery.
3. Contaminated- Perforated appendectomy, colectomy for diverticulitis, perforated ulcer or bowel, penetrating GI trauma. Give 2nd gen Ceph or Ampicillin/Gentamycin/Flagyl
4. Dirty- traumatic wounds, burns older than 72 hours, free colon perforation
* Keep skin OPEN in classes 3 and 4.
96
Fornier's gangrene is a type of _______ that originates in the urethral glands and spreads to the perineal tissue.
Necrotizing fasciitis
97
Treatment of necrotizing fasciitis includes:
1. Debride tissues
2. Abx and hemodynamic support with IV infusion
- Ampicillin/sulbactam (Unasyn) + Clindamycin + Cipro
- Add Vanc if there's a concern for MRSA
98
_____ most often occurs in the LE and pelvis: 80% in deep veins of calf, 20% femoral or iliac vein
DVT
99
Precipitators of DVT include:
Prolonged bed rest or immobility, long air travel, malignancy, nephrotic syndrome, use of OCPs and hormone replacement therapy, and hypercoaguable syndromes (protein C/S, Factor V Leiden, Antithrombin III, PNG, homocystinuria)
Also- advanced age, type A blood, obesity, multiparity, IBD, lupus,
100
S&S of DVT include:
Dull aching pain in leg that is worse with walking, edema, palpable cord, low grade temperature, tachycardia
*Homan's sign about 50% of the time (pain with dorsiflexion)
101
How is DVT diagnosed?
1. Duplex US is preferred study!! (Doppler analysis similar and also used)
2. Venography is most accurate method but has increased risk
3. D-dimer--> a fibrin degradation product that is elevated in the presence of thrombus
* An elevated D-dimer does NOT diagnose, BUT a negative D-dimer test can r/o and omit need for US
**If pulmonary emboli suspected- VQ scan versus spiral CT
102
Preferred treatment for DVT is ______ (med)
LMWH (preferred over continuous IV infusion of unfractionated heparin)
* Heparin followed by warfarin may be used
* *Need heparin until INR is therapeutic for 48 hrs
103
How long will a patient need to remain on warfarin after DVT?
*1st event and idiopathic: 6 months
**Non-idiopathic or recurrent event: consider indefinite therapy
104
Thrombolytic therapy indicated in:
Younger patients with large (ileofemoral) thrombi that are detected within 2 weeks of onset
105
Embolectomy (now can be done percutaneously) gaining popularity. One advantage over lytic therapy is:
There is a decreased bleeding risk
106
______ used in cases of contraindication to anticoagulation, failure of anticoagulation, or prophylactic use against high-risk of PE.
IVC filter
107
What is Wells Criteria?
1. Clinical evidence for DVT= 3pts
2. PE is number one diagnosis= 3pts
3. HR > 100 bpm= 1.5pts
4. Immobilization/Surgery in past 4 weeks= 1.5pts
5. Previous DVT/PE= 1.5pts
6. Cancer= 1pt
7. Hemoptysis= 1pt
*Score of < 2 makes diagnosis highly unlikely. SCORE > 6= LIKELY DVT/PE
108
Clinical RFs for perioperative DVT:
- Older
- Prolonged immobility/paralysis
- Prior DVT
- Cancer
- Major surgery (abdomen/pelvic)
- Obesity
- Varicose veins
- CHF
- MI
- Stroke
- Fractures of pelvis, leg, hip
- Indwelling femoral vein catheters
- IBD
- Nephrotic syndrome
- Estrogen use
- Hypercoaguable state
109
DVT prophylaxis includes:
Heparin- 5000 units subcutaneously started 2 hours before the operation and continued every 8-12hrs after surgery until fully ambulatory or discharged
*Or Enoxaparin- 40mg qd. Also SCDs and/or compression stockings
110
During laparotomy, estimated evaporative fluid loss is ____mL/kg/hr.
10
111
______ is the most frequent d/o in the preoperative patient.
Dehydration w/ accompanying salt loss
112
If patient is febrile, maintenance fluid must be increased by 10% for each degree above ____.
37.2C
113
IV requirements for HYPERnatremia:
| May see with TPN
Water in 5% dextrose
114
IV requirements for HYPOnatremia:
Water restriction; may need hypertonic saline (watch out for fluid overload!)
115
Pure water excess usually due to _____ and seen in patients with CNS lesions and burns.
SIADH
*Mannitol is treatment of choice
116
Metabolic acidosis is defined by a pH < ___ and plasma bicarb < ____.
7.35; 22mEq/L
117
Causes of Anion Gap Metabolic Acidosis:
DR. MAPLES
| Diabetic ketoacidosis, Renal failure, Methanol, Alcohol, Paraldehyde, Lactic acidosis, ethylene glycol, salicylates
118
Causes of Non-anion Gap Metabolic Acidosis:
Characterized by lack of buffer base-
GI tract losses, renal tubular acidosis, Addison's, TPN, and use of carbonic anhydrase inhibitors (anti-convulsant, glaucoma, diuretic).
119
Metabolic acidosis can lead to:
Myocardial depression, HYPOtension, arrhythmias, HYPERkalemia, insulin resistance, obtundation, coma
120
Treatment of metabolic acidosis depends on etiology:
1. Trauma- restore blood and fluid
2. DKA- manage insulin and restore volume
3. If acidosis is severe treat with sodium bicarbonate
121
Metabolic Alkalosis is usually accompanied by respiratory compensation, or an increase in _____.
pCO2
122
Some causes of metabolic alkalosis are:
1. Chloride responsive- nasogastric losses, vomiting, past use of diuretics, volume contraction, posthypercapnic
2. Chloride resistant- aldosteronism, renal artery stenosis, renin-secreting tumor, Cushings.
* Severe metabolic alkalosis is associated with cerebral hypoperfusion and HYPOkalemia
123
Treatment of metabolic alkalosis includes:
Saline, carbonic-anhydrase inhibitor (acetazolamide)
124
Respiratory acidosis is defined by a ____ (high/low) pH and a (high/low) pCO2.
low; high
125
Causes of respiratory acidosis include:
Decompensation of preexisting respiratory disease, asthma, neuromuscular disorders, CNS depression, airway obstruction.
126
Plasma bicarb concentrations do not increase much in ____ (acute/chronic) cases of respiratory acidosis. In _____ (acute/chronic), renal adaptation is substantial.
acute; chronic
127
In Respiratory Alkalosis pH is (low/high) and pCO2 is (low/high).
high; low
128
Respiratory alkalosis is caused by alveolar _____ (hypo/hyperventilation).
HYPERventilation
129
In surgical patients, respiratory alkalosis may be due to:
Hypoxia, CNS lesions, pain, hepatic encephalopathy, mechanical ventilation
130
Most patients with respiratory alkalosis are ______ (symptomatic/asymptomatic).
Asymptomatic
131
The most accurate method for diagnosing thrombophlebitis in the lower leg is _____
Venography
132
A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of pericardial tamponade is strongly supported by the presence of:
Distended neck veins- Cardiac compression will manifest with distended neck veins and cold clammy skin.
