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Emergency Medicine > Chest pain > Flashcards

Chest pain Flashcards

1
Q

What RF can increase atherosclerosis

A
  1. cocaine
  2. HIV
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2
Q

classic presentation of CP

A
  • Retrosternal in L anterior chest
  • Crushing, tightness, squeezing, or pressure
  • Worsened w/ exertion
  • Alleviated w/ rest
  • Dyspnea, diaphoresis, nausea
  • Radiation to L shoulder, jaw, arm, or hand
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3
Q

onsets of classic chest pain presentations

A

Sudden or gradual:
* Angina: 2-10 min
* Unstable angina: 10-30 min
* AMI pain: >30 min

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4
Q

Two categories of ”chest pain” based on nerve fiber:

A
  1. Visceral:
    - Located in heart, blood vessels, esophagus, and visceral pleura
    - Pain difficult to describe and localize
    - Discomfort, heaviness, pressure, tightness, aching
    - Pain can radiate
  2. Somatic:
    - Innervates chest wall, from dermis to parietal pleura
    - Easily described and precisely located
    - Sharp, stabbing, scratchy, without radiation
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5
Q

atypical CP presentation can be seen in who?

A
  1. Pre & early menopausal women
  2. Racial minorities
  3. DM
  4. Elderly
  5. Pts w/ psychiatric disease or AMS
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6
Q

If any of these sx are present, it is unlikely an AMI:

A
  1. pleuritic in nature
  2. Positional
  3. sharp
  4. reproducible with palpation/positioning
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7
Q

Possible PE findings for cardiac CP

A
  1. Tachycardia - ↑ sympathetic tone, ↓ LV stroke volume
  2. Bradycardia - ischemia to conduction system
  3. Acute ischemia -
    - 3rd/4th HS from changes in ventricular compliance
    - new murmur from ruptured cordae tendineae
    - aortic root dissection, or crackles on lung auscultation from CHF.
  4. Chest wall tenderness in 15% of pts, unlikely to be useful by itself to exclude ACS
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8
Q

perform an EKG within ___ min if concern for myocardial ischemia

A

10

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9
Q

ECG findings of acute MI
tx?

A

new ST elevations ≥1 mm in two contiguous leads
rapid reperfusion interventions

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10
Q

ECG findings of ____ indicate ischemia → further eval

A

New ST elevations, Q waves, LBBB, T-wave inversions or normalizations in sx pts

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11
Q

CXR of classic CP presentation

A

nml MC
r/o thoracic aortic aneurysm, aortic dissection, pneumonia, pneumothorax, PE

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12
Q

next imaging choice after CXR?
r/o for what dx?

A

Non-contrast CT
PNA, pneumothorax

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13
Q

imaging modility for aortic aneurysm/dissection or PE

A

Chest CTA

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14
Q

ECHO Emergent may be useful with what severe dx?

A
  • aortic dissection, cardiac tamponade, new regurg murmur
  • This will vary on the hospital and staff/providers available
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15
Q

Other tests based on suspected DDx for chest pain

A
  1. CBC
  2. BMP or CMP
  3. PT/PTT
  4. ABG
  5. Type and Crossmatch
  6. Hcg in women of childbearing age
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16
Q

Best serum marker for myocardial injury

A

Troponin

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17
Q

AMI troponin measurements (onset, peak, elevated)

A
  1. Onset: 4 hours after onset of acute MI
    - More reliable 6 hr after sx.
  2. Peak: 24-48 h
  3. Elevated: 10 d
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18
Q

which serum marker

  • useful if timing of infarction remains unclear
  • used only if troponin isn’t available or if pt has had an MI in the last 2-3 days
  • levels normalize in 48-72 hrs
A

CK-MB

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19
Q

Red flags during initial triage for chest pain

A
  1. Abnormal vital signs
  2. Concerning EKG findings (if already performed)
  3. Hx prior CAD
  4. Multiple ASCVD risk factors
    - Advanced age, HTN, tobacco use, HLD, DM, obesity, family hx, ASCVD, sedentary lifestyle
  5. Abrupt onset, new or severe chest pain or dyspnea
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20
Q

Hx for initial chest pain triage

A
  • Should be FOCUSED!
  • Include sx and the 7 attributes
  • Focused PMH
  • Assess for risk factors
  • ROS - focused on DDx
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21
Q

sudden, pleuritic CP, focal chest w/ dyspnea, tachypnea, tachycardia, or hypoxemia.

what ddx

A

Pulmonary Embolism

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22
Q

RF for Pulmonary Embolism

A

prolonged immobilization, active cancer, recent surgery/trauma, procoagulant syndromes, exogenous estrogen, or previous thromboembolic disease.

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23
Q

Criterias used for PE

A

Wells, Revised Geneva Scores, PERC

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24
Q

diagnostics for PE

A

D-dimer
CT pulm angiography

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25
Q
  • sudden, severe, tearing pain radiating to scapula; midline, substernal
  • Secondary sx - ischemic stroke, AMI, limb ischemia; unilateral pulse deficits or focal neuro deficits
A

aortic dissection

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26
Q

RF aortic dissection

A

male, >50y, uncontrolled HTN, CTD, cocaine, bicuspid valve or AV replacement, pregnancy

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27
Q

dx aortic dissection?

A

CT aortogram / TEE
Nml CXR and (-) D-dimer does NOT r/o dissection
nonspecific ST or T-wave changes on ECG possible

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28
Q
  • sudden, sharp substernal CP after episode of forceful vomiting; ill appearing w/ tachycardia, F, dyspnea, and diaphoresis
  • Crepitus in neck/chest from SQ emphysema
A

Esophageal Rupture (Boerhaave’s Syndrome)

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29
Q

what is Hamman’s crunch

A

crepitus on cardiac auscultation

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30
Q

diagnostic for Esophageal Rupture (Boerhaave’s Syndrome)

A
  • CT of chest w/ oral water-soluble contrast
  • Nml or pleural effusion (left MC), pneumothorax, pneumomediastinum, pneumoperitoneum, or subcutaneous air.
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31
Q

esophageal rupture most often in the _____ of the esophagus, resulting in a _____

A

distal ⅓ of the esophagus resulting in a pneumomediastinum

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32
Q

tx esophageal rupture

A
  1. Stabilize air way
  2. NPO, IV fluids
  3. Broad spectrum IV antibiotics
  4. 1st line: ampicillin/sulbactam or pip/taz
    - BL allergy: clindamycin + ciprofloxacin
  5. NG or OG tube placement - prevent further saliva and gastric content contamination
  6. Consult surgery
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33
Q

sudden, sharp, pleuritic CP w/ dyspnea; ↓ breath sounds on affected side
MC tall, slender male pts

A

Spontaneous Pneumothorax

RF: smoking, COPD, and asthma
Dx: CXR

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34
Q

sharp, severe, constant, and retrosternal that radiates to back, neck, or jaw; worsened supine, relieved sitting forward; pericardial friction rub

A

Acute Pericarditis

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35
Q

ECG shows PR depressions, diffuse ST-segment elevations, or T-wave inversions; diffused

what dx?

A

Acute Pericarditis

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36
Q

CP worsened w/ movement of chest and palpation; CP d/t irritation/inflammation

A

MSK Causes

  • Causes: costochondritis, xiphodynia, precordial catch syndrome, intercostal strain d/t coughing, pectoralis muscle strain w/ recent physical exertion.
  • Clear MSK etiology + completely reproducible pain w/o other sx or RF
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37
Q

s/s of GI causes of CP

A
  1. Gastritis: gnawing / burning pain in lower chest
  2. PUD: postprandial dull, boring pain in epigastric region
  3. Esophageal spasm: reflux disease; sudden onset of dull or tight substernal chest pain; precipitated by drinking cold liquids and can be relieved by NTG
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38
Q

initial management for chest pain

A
  1. Placed in a treatment bed quickly
  2. Cardiac monitoring and IV access (2 large bore)
  3. EKG (within 10 minutes)
  4. Measure vital signs, then resuscitate as needed, following the ABCs
  5. supplemental O2 if O2 saturation at rest is < 95%*
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39
Q

for chest pain presentation; admit if they meet this criteria:

A
  1. Positive cardiac enzymes
  2. New concerning EKG changes
  3. Persistent pain
  4. Concerning physical exam findings
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40
Q

Heart Scoring

A

0-3 = DC
4-6 = Admit to observe
7-10 = early invasive strategies

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41
Q

MC sx of ACS

A
  1. MC Chest pain
    - substernal or left-sided CP,
    - radiation to one or both arms, accompanied with N/V, diaphoresis.
    - “Pressure”
    - Exertional
  2. Pallor, diaphoresis, AMS, elevated JVD, peripheral edema, or rales
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42
Q

atypical sx for ACS

A

SOB, N, diaphoresis, back pain, abd pain, dizziness, palpitations

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43
Q

RF for CAD

A

older, male, FHx, smoking, HTN, hypercholesterolemia, DM, cocaine

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44
Q

presentation of unstable angina

A

CP (or atypical ACS sx) + obstructive CAD and has one of the following:

  1. began within past 2 months
  2. has increasing frequency, intensity, or duration of existing angina sx
  3. existing angina begins to occur at rest
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45
Q

Dx ACS

A

cTn, CBC, lytes, PT/PTT, CXR

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46
Q

goals for care in ACS

A
  1. reperfusion by reducing thrombus
  2. limiting thrombus extension
  3. relieving obstructive CAD
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47
Q

tx options for STEMI

A

systemic thrombolytic 30 min of arrival / PCI 90 min
PCI preferred - greater benefits and fewer risks if no CI to thrombolysis who can achieve PCI within 120 min.

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48
Q

If no PCI is available, what do you use

A

fibrinolytics IF:

  1. < 6-12 hrs of sx onset
  2. ECG 1 mm ST elevation in 2 contiguous leads
  3. Full dose anticoag for 48 hrs
  4. Avoid: arterial puncture, venipuncture, central lines in areas which are not readily compressible
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49
Q

tx for suspected ACS

A
  1. cardiac monitoring, IV line, O2 if < 95%.
  2. ASA 160-325 mg PO chewed; Alt: Clopidogrel
  3. NTG PO, transdermal, or IV to treat any ongoing angina.
  4. Morphine if pain continues despite NTG.
  5. Metoprolol in first 24h
  6. +/- antiplatelet
    - Dual therapy: clopidogrel w/ ASA
    - Antithrombin: heparin/enoxaparin
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50
Q

which med recommended for use along with aspirin in pts w/ mod-high risk NSTEMI and STEMI, and in all pts in whom PCI is planned?

A

Clopidogrel

Hold 5 d before CABG - ↑ risk of bleeding

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51
Q

which anticoag options for use in unstable angina or NSTEMI pts?

A
  • LMWH - Can be used in PCI revascularization
  • Unfractionated heparin - CABG
  • Factor Xa inhibitor - fondaparinux - Similar efficacy to unfractionated; Good for renal impaired
  • Direct thrombin inhibitor - Bivalirudin - Less bleeding and no dosage adjustment in renal impairment ; Alt in STEMI to unfractionated and GP IIb/IIIa inhibitor
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52
Q

tx STEMI

A

immediate cath

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53
Q

tx for CP treated Thrombolytics but still hemodynamic instability and pain / have not reperfused

A

rescue angioplasty
Emergent CABG may also be indicated for some patients.

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54
Q

tx for Refractory cardiogenic shock

A

emergent angioplasty
Other: Intraaortic balloon pump or other LVADs
Admitted to critical care unit

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55
Q

tx NSTEMI or unstable angina w/ ongoing CP, ECG changes, dysrhythmias, or hemodynamic compromise

A

admitted in cardiac ICU

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56
Q

tx for Unstable angina but no/resolved s/s

A

admitted to monitored inpatient bed

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57
Q

thrombolytic options

A
  1. tPA
  2. Reteplase (rPA) - Pro: double bolus rather than continuous infusion
  3. Tenecteplase (TNK) - alt for tPA
  4. Streptokinase (SK)
    - Can cause allergic reaction
    - CI: HoTN, prior SK within 6 mo, strep within year
    - Start heparin within 4 hrs of starting SK
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58
Q

complications for thrombolytics?
tx?

A

bleeding/intracranial hemorrhage

  1. DC thrombolytics, heparin, ASA
  2. Crystalloid and RBC infusion possible
  3. Cryoprecipitate + FFP
  4. 10 U cryoprecipitate and get fibrinogen levels
    - < 1 g/L - +10 U
    - Still Bleeding but >1 g/L or < 1 g/L after 20 U → 2 U FFP
    - Bleed continues → platelets / antifibrinolytic (aminocaproic acid or tranexamic acid)
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59
Q

what med is given the first 24 hrs of admission if significant tachycardia or HTN for ACS/MI/unstable angina?

A

BB PO

60
Q

Upon completion of the primary evaluation, classify patients into one of
the following categories of the prognosis-based classification system: (4)

A
  1. Acute myocardial infarction (AMI)
  2. Probable acute ischemia - Additional TIMI & HEART
  3. Possible acute ischemia - Additional TIMI & HEART
  4. Definitely not ischemia
61
Q

secondary assessment for CP pt with No ST elevation

A

serial cTn to r/o MI

  • Low-risk - 2 cTn measurements 2 hrs apart; one measurement at least 6 hrs after onset of pain
  • Does not r/o unstable angina
62
Q

secondary assessments for continued suspicion for ACS w/ negative biomarkers

A

cardiac testing

  1. exercise/pharm ECG stress test
  2. Stress Test: echo, nuclear imaging, MRI
  3. CTCA
  4. Cath
63
Q

MC cardiomyopathy

A

Dilated cardiomyopathy

idiopathic (MC), familial, secondary

64
Q

what is Peripartum CM

A

dilated cardiomyopathy affecting pregnant women from 20 wks into postpartum period

65
Q

what type of cardiomyopathy condition is the primary indication for cardiac transplant?

A

dilated CM

66
Q

s/s Dilated CM

A
  1. Acute HF from systolic pump dysfunction
    - DOE, orthopnea, paroxysmal nocturnal dyspnea
    - Rales, dependent edema, hepatomegaly, holosystolic murmur
    - CP possible
67
Q

diagnostic findings of dilated CM

A
  • ECG → LVH, LAE, Q/QS waves, poor R wave progression across precordium
  • CXR → enlarged cardiac silhouette, biventricular enlargement, pulm vascular congestion
  • Dx: ECHO → ↓ EF, ventricular enlargement, ↑ systolic & diastolic volumes
68
Q

management for new and old dilated CM?

A
  1. New - admit; monitored or ICU
  2. Known CM → identify cause - MI, anemia, infection, afib, bradyarrhythmia, valvular insufficiency, renal dysfunction, PE, thyroid dysfunction
69
Q

complex ventricular ectopy in dilated cardiomyopathy may be treated with ?

A

amiodarone

70
Q

chronic therapy for dilated CM

A
  1. diuretics, digoxin - improves sx, no effect on survival
  2. ACE, BB (carvedilol) - better for survival
71
Q

management for advanced dilated CM

A

LVADs while awaiting transplant

72
Q

a common cause of dilated CM
Inflammation of myocardium - Systemic disorder or infectious agent
Pericarditis MC accompanies

A

Myocarditis

73
Q

s/s Myocarditis

A
  • Nonspecific - Myalgias, HA, rigors, F, tachycardia
  • CP, pericardial friction rub
  • Severe - HF: DOE, Rales, Pedal edema, Cardiogenic shock
74
Q

w/u for myocarditis

A
  1. ECG - nml; nonspecific
    - AV block , prolonged QRS, ST elevation, PR depression
  2. CXR - nml; pulm congestion (severe)
  3. Biomarkers - elevated
75
Q

management for myocarditis

A
  1. Admit, supp care = mainstay
  2. Abx with suspected bacterial myocarditis
  3. Progressive HF - ICU
76
Q

what is a LVAD

A

Implanted pump transferring blood from apex of LV to proximal aorta

77
Q

PE of LVAD

A
  1. Pump creates continuous blood flow to maintain nml MAP - May not have nml palpable pulse
  2. BP obtained by doppler or mechanical cuff
  3. “Whirr” heart sound from LVAD pump
  4. ECG - discernible QRS
  5. CXR - LVAD components
78
Q

NEVER perform what intervention on an LVAD pt with hemodynamic instability?
why?

A
  1. CPR → displaces LVAD
  2. LVAD causing LV rupture with intractable hemorrhage
79
Q

process of listening to the heart with LVAD pt

A
  1. “Whirr” heard → get BP, place on monitor, IV access, nml saline bolus
  2. No “whirr” → enlist the pt and family to help find cause of mechanical failure and change battery and controller; do not disconnect any equipment
80
Q

common complications and tx of LVAD

A
  1. Infection at abdominal wall outlet → abx
  2. Anemia secondary to red cell destruction from pump/hemorrhage from anticoag → blood transfusion
  3. Thromboembolic event - heparin once bleeding r/o
81
Q

LVAD: HoTN persists or RV failure, what tx?

A

pressors

82
Q

what is hypertrophic CM

A

Asymmetric LVH and/or RVH involving interventricular septum = ↓ compliance of LV → impaired diastolic relaxation and diastolic filling

83
Q

s/s hypertrophic CM

A
  1. More severe when older
  2. DOE MC
  3. CP, palpitations, syncope; may be aware of forceful ventricular contractions
  4. S4 HS, systolic ejection murmur heard at lower left sternal boarder or apex = does not radiate to neck
    - Enhanced by valsalva or stand
    - ↓ by squatting and passive leg elevation - ↑ LV filling
84
Q

EKG findings of HCM

A

nonspecifc; LVH, LAE, deep S waves with large septal Q waves and upright T waves possible
Inverted T waves = ischemia

85
Q

dx HCM?

A

echo = disproportionate septal hypertrophy

CXR nml

86
Q

management for HCM

A
  1. Mainly supp
  2. Suspected hypertrophic CM → echo
  3. Suspected hypertrophic CM + syncope → admit for cardiac monitoring and eval - sudden cardiac death!!
  4. When definitive dx → atenolol
87
Q

CM - Uncommon; idiopathic or secondary
Sarcoidosis, scleroderma, amyloidosis
Ventricular filling restricted → nml or diminished diastolic volume, systolic nml

A

Restrictive CM

88
Q

s/s Restrictive CM

A
  1. Dyspnea, orthopnea, pedal edema W/O assoc CM or systolic dysfunction
  2. CP UNCOMMON
  3. PE - consistent with degree of disease
    - S3/S4
    - Cardiac gallop
    - Rales
    - JVD, inspiratory JVD (kussmaul sign)
    - Hepatomegaly
    - Pedal edema
    - Ascites
89
Q

diagnostic findings in restrictive CM

A
  • ECG - nonspecific; conduction disturbances, low voltage (sarcoidosis/amyloidosis)
  • CXR - HF w/o cardiomegaly
90
Q

management for restrictive CM

A
  1. Admit
  2. Diuretics & ACEI → sx control
  3. Tx underlying
    - Sarcoidosis → corticosteroid
    - Hemochromatosis → chelation
91
Q

what is Acute Pericarditis including causes

A
  • Inflammation of layers covering heart
  • Idiopathic or infection (virus, bacterial, fungus)
  • Causes: malignancy, drugs, radiation, CTD, uremia, myxedema, postmyocardial infarction (Dressler’s syndrome)
92
Q

MC - sharp/stabbing precordial or retrosternal CP - radiating to back, neck, shoulder, or arm
Worsens lying supine, movement, swallowing, inspiration
Alleviated by sitting up and leaning forward
Assoc sx - infection, low-grade F, dyspnea, dysphagia
PE - nml; friction rub at lower left sternal border or apex

what dx

A

acute pericarditis

93
Q

ECG acute pericarditis

A

Stage 1 - diffused ST elevation - I, V5, V6; PR depression II, aVF, V4-6
Stage 2 - ST normalized; T-wave amplitudes ↓
Stage 3 - T-wave inversion - I, V5, V6
Stage 4 - Normalized ECG

94
Q

if sequential EKGs are not avail, what EKG findings are suggestive of pericarditis?

A

ST-segment/T-wave amplitude ratio > 0.25 in leads I, V5, or V6

95
Q

tx for Stable, idiopathic/presumed viral pericarditis

A

outpatient, ibuprofen

96
Q

ED mgmt when to admit pericarditis pts?

A
  • Colchicine - beneficial adjuvant, can prevent recurrence
  • Pericarditis + myocarditis/enlarged cardiac silhouette/effusion via echo/uremic pericarditis/ hemodynamic compromise → admit
97
Q

Fluid accumulation in pericardial space → exceeds pressure of RV → tamponade = restricted filling and ↓ CO

A

Nontraumatic cardiac tamponade

98
Q

causes of Nontraumatic cardiac tamponade

A
  1. uremia
  2. malignant effusion/Metastatic Malignancy
  3. hemorrhage d/t anticoag
  4. bacterial or tubercular infection
  5. chronic pericarditis
  6. lupus, radiation, myxedema, idiopathic
  7. Penetrating or blunt chest wall trauma
99
Q

Development of diastolic dysfunction results in relation to:

A
  1. rate of fluid accumulation
  2. pericardial compliance
  3. intravascular volume (hypovolemia lowers ventricular filling pressure)
100
Q

s/s cardiac tamponade

A
  1. Mild to severe shock
  2. MCC - dyspnea
  3. Tachycardia, HoTN/low SBP, narrow pulse pressure
  4. Pulsus paradoxus - drop in SBP >10 during normal inspiration
  5. Neck vein distention, distant HS, RUQ pain (hepatic congestion)
  6. NO RALES
  7. Beck’s Triad of Cardiac Tamponade
    - Hypotension
    - JVD
    - muffled heart sounds
101
Q

ECG of cardiac tampanode

A
  • low-voltage/small QRS, ST elevations w/ PR depression as in pericarditis
  • Electrical alternans
102
Q

diagnostic for cardiac tampanode

A

TTE - Large pericardial effusion with RA/RV diastolic collapse
TTE - most sensitive and specific; US can be used too

103
Q

cardiac tampanode can lead to HoTN and cardiac arrest with ____

A

pulseless electrical activity (PEA)

104
Q

mgmt cardiac tampanode

A
  1. Peripheral IV, O2, continuous cardiac monitoring
  2. BP monitoring q5-15 min
  3. IV saline/Large bore IV fluids - helps with right heart filling, temp improves hemodynamics
  4. Pericardiocentesis when hemodynamically stable
    - Emergency pericardiocentesis
    if signs of decompensation, performed at bedside with US and/or EKG guidance
    - Urgent consult to cardiology and cardiothoracic surgery for pericardiocentesis
105
Q

what is constrictive pericarditis

A
  • Pericardial injury/inflammation → abnml diastolic filling → constrictive pericarditis
  • Causes: fungal, TB pericarditis, uremic pericarditis, postcardiac trauma, post surgical changes after pericardiotomy
106
Q

presentation constrictive pericarditis

A
  1. Gradual development of sx similar to HF and restrictive CM
    - DOE, pedal edema, hepatomegaly, ascites
    - Kussmaul’s sign frequent
107
Q

w/u and findings for constrictive pericarditis

A
  1. ECG: Nonspecific; small QRS, inverted T waves
  2. CXR - nml; enlarged cardiac silhouette
  3. 2D Echo - not helpful!!
  4. Dx: CT/MRI/Doppler echo
108
Q

mgmt constrictive pericarditis

A
  1. Eval ventricular function
  2. Surgical pericardiectomy if significant construction and impaired ventricular filling
109
Q

AAA definition

A
  1. ≥3.0 cm in diameter
  2. Symptomatic aneurysms and ≥5.0 cm require prompt operative repair
  3. Emergent!!
110
Q

classic presentation of aortic rupture

A
  • Older male, smoker, atherosclerosis; Sudden severe back or abd pain; HoTN; Pulsatile abdominal mass
  • Syncope, pain localized to flank, groin, hip or abdomen possible
  • Severe and abrupt ripping/tearing pain = rupture
  • Femoral pulsations nml
  • Retroperitoneal hemorrhage rarely
111
Q

Aortoenteric fistula presentation

A
  • GI bleeding - small or life-threatening
  • H/o aortic grating at higher risk
  • Duodenum MC site for fistula
  • Hematemesis, melena, hematochezia
  • High output cardiac failure with ↓ arterial blood flow distal to fistula
112
Q

presentation of Rupture into retroperitoneum

A
  • Fibrosis → chronic contained rupture
  • Appear nml, may have pain for long time before dx is made
113
Q

MC incorrect initial dx of aortic rupture/AAA

A

Renal colic
Back pain, intraabdominal process, testicular torsion , GI bleeding

114
Q

additional w/u when dx is unclear with AAA

A
  1. Bedside abd US - >90% sensitivity
    - Aortic rupture/retroperitoneal bleed not reliably identified
  2. CT - can delineate where aneurysm and any associated rupture
115
Q

possible XR finding with AAA

A

calcified, bulging aortic contour (only in some)

116
Q

general mgmt for AAA

A
  • Consult vascular surgeon if rupturing AAA or aortoenteric fistula
  • Fluids (for HoTN)
  • Target SBP: 90mmHg
  • Tranfuse PRBC if needed
  • Pain control while avoiding HoTN
117
Q

tx small asx AAA (3-5 cm)

A
  • Incidental finding
  • Refer to vascular surgeon
118
Q

tx for Large AAA (>5cm)

A

Higher risk for spontaneous rupture; close f/u

119
Q

dx & mgmt/tx for Nonaortic large-artery aneurysms

A

Dx: US/CT
1. Popliteal/femoral - thrombolysis, ligation, arterial bypass, endovascular repair
1. Hepatic - surgical ligation, embolization
1. subclavian/femoral pseudoaneurysm/ renal/splenic - surgical repair
- renal/splenic - +ectomy

120
Q

for Aortic Dissection, the blood dissects between ___ and ___ layers of aorta

A

intimal
adventitial

121
Q

RF aortic dissection

A
  1. MC male, >50y, h/o HTN
  2. Chronic cocaine use
  3. h/o cardiac surgery
  4. Younger pts - CTD, congenital heart disease, pregnancy - Marfan’s syndrome
122
Q

presentation aortic dissection

A

Acute CP
- Most severe at onset
- Radiates to back
- Sharp, ripping, tearing pain
- Syncope possible
- Location dependent on area of aorta involved:
— Anterior CP - ascending aorta
— abd/back pain - descending aorta
— Diastolic murmur of aortic insufficiency possible
— HTN and tachycardia common; HoTN can be present
- ↓ pulsation in radial, femoral, or carotid arteries
- Neurologic sequelae

123
Q

what is Stanford Classification ?

A

aortic dissection

Type A - Ascending Aorta
Type B - descending Aorta

124
Q

what is DeBakery Classification

A
  • Type I - ascending & descending
  • Type II - ascending only
  • Type III - descending only
125
Q

presentation of progressed dissection

A
  • AV insufficiency
  • coronary artery occlusion - myocardial infarction
  • carotid involvement - stroke sx
  • occlusion of vertebral blood supply - paraplegia
  • cardiac tamponade - shock and JVD
  • compression of recurrent laryngeal nerve - hoarseness of the voice
  • compression of superior cervical sympathetic ganglion - Horner’s syndrome.
126
Q

w/u and findings with dissection? What is the diagnostic w/u?

A
  1. D-Dimer
  2. CXR
    - MC - Abml aortic contour, widening mediastinum
    - Deviated trachea, mainstem bronchi, esophagus, apical capping, pleural effusion, displacement of aortic intimal calcifications
  3. Dx: CT w/ contrast; TEE
127
Q

tx aortic dissection

A
  1. Consult vascular or thoracic surgeon
  2. Fluids
  3. Esmolol/labetalol
    - Goal HR: 60-70
    - Goal SBP: 100-120
  4. SBP >120 → nitroprusside/nicardipine
128
Q

HTN emergency definition

A

Defined as a SBP >180 and/or DBP >120

BP should be assessed in both arms multiple times

129
Q

Two types of hypertensive crisis

A
  1. HTN urgency - no evidence of end-organ damage
  2. HTN emergency - evidence of end-organ damage
    - brain, heart, aorta, kidneys, eyes
130
Q

s/s of HTN emergency

A
  1. Brain: HTN encephalopathy, SAH, ICH, Ischemic CVA
  2. Heart: Acute pulmonary edema, MI, ACS
  3. Aorta: Aortic dissection
  4. Kidney: Acute renal failure
  5. Eyes: Hypertensive retinopathy
  6. Multiorgan: Preeclampsia, Eclampsia, Acute perioperative HTN, Sympathetic crisis
131
Q

for HTN emergencies how do you eval them?

A

Look for signs of end-organ damage
H&P

  1. Mental status changes, neurologic dysfunction, seizure, acute severe HA
  2. Visual changes, retinopathy, papilledema
  3. Sudden onset chest pain
  4. Dyspnea
  5. Peripheral edema
  6. Oliguria
132
Q

labs that indicate end-organ damage

A
  1. BMP: acute elevation of serum creatinine
  2. UA: proteinuria, RBC, or red cell casts
133
Q

imaging needed for HTN emergencies

A
  1. CXR - pulmonary edema or thoracic aortic dissection
  2. ECG - cardiac ischemia
  3. CT head w/o contrast - neurologic changes/CVA
    - Follow up with CTA head & neck if noncontrast CT is negative
  4. CTA chest - chest pain/aortic dissection
134
Q

tx HTN urgency

A
  1. BP control within 24–48 hours
  2. No hx of HTN: HCTZ
  3. Hx of HTN: reinstitution or intensification of oral antiHTN
  4. DC home with rapid follow-up with PCP
135
Q

tx HTN emergency

A
  • Rapid, controlled reduction in BP w/ IV antiHTN
  1. Reduce SBP by no more than 25% in the first hour
  2. If stable: reduce to 160/100 over next 2-6 hrs
  3. If stability remains reduce to normal over the following 24 to 48 hour
  • Admit to a critical care floor (CCU, ICU)
136
Q

3 conditions that are the exception in reducing SBP by no more than 25% in the first hour during HTN emergency

A

Aortic dissection, acute ischemic strokes, intracerebral hemorrhage

137
Q

HTN emergency: Rapid reduction of BP can lead to ?

A

watershed cerebral infarction

138
Q

which agent is preferred for SAH, ischemic stroke

A

Nicardipine (Cardene) - CCB

139
Q

Nicardipene may precipitate myocardial ischemia, what other agents are alternatives

A
  1. Labetalol (Trandate)
  2. Enalaprilat (Vasotec)
140
Q

which antiHTN agent is used in most patients, aortic dissection, stroke

A

Labetalol (Trandate)

141
Q

which antiHTN agent is preferred for aortic dissections

A

Esmolol (Brevibloc)

142
Q

which antiHTN agent is preferred for renal insufficiency or failure; May protect kidney function.

A

Fenoldopam (Corlopam)

143
Q

which antiHTN agent is preferred for CHF, stroke

A

Enalaprilat (Vasotec)

144
Q

which antiHTN agent is preferred in pregnancy

A

hydralazine (apresoline)

Avoid in CAD, dissection. Rarely used except in pregnancy.

145
Q

which 2 antiHTN agents should be avoided in acute LV systolic dysfunction, asthma.

A

Labetalol (Trandate)
Esmolol (Brevibloc)

146
Q

which antiHTN agent is no longer the first-line agent d/t wide variety of SE?

A

Nitroprusside (Nitropress)

Emergency Medicine (20 decks)

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