Chest Pain Flashcards
(64 cards)
1
Q
When is morphine contraindicated?
A
In patients with respiratory depression/failure
2
Q
Agent of choice for patients with hyperkalemia and EKG changes?
A
Calcium gluconate
3
Q
Drug for SVT?
A
- Adenosine (short acting AV blocking agent)
2. Vagal maneuvers
4
Q
What drugs are commonly used for wide complex V-tach?
A
- Amiodarone
- Sotalol
- Procainamide
- Lidocaine (2nd line)
5
Q
First line treatment for decompensated CHF with pulmonary edema?
A
NTG. Is a preload reducer (increase venous capacitance).
6
Q
When do patient’s with a-fib need anti-coagulation (time frame)?
A
> 48h or unknown duration
7
Q
What drug (which is sometimes used for rate control in a-fib) is contraindicated for a-fib if a patient has symptoms of CHF?
A
B-blocker b/c of effect on intropy.
8
Q
Relative contraindications to t-PA?
A
- Systolic > 180
- Current anticoagulation
- Major surgery within 3w
- PUD
9
Q
Absolute contraindications to t-PA?
A
- Previous hemorrhagic stroke
- Intracranial neoplasm
- Active internal bleeding (including menses)
- Suspected aortic dissection or pericarditis
10
Q
6 T’s
A
- Toxins
- Tamponade
- Tension pneumo
- Thrombosis (coronary)
- Thrombosis (pulmonary)
- Pulmonary
11
Q
5 H’s
A
- Hypovolemia
- Hypoxia
- Hydrogen ions
- Hyper/hypokalemia
- Hypothermia
* 6. Hypoglycemia
12
Q
How effective is glucagon for food bolus?
A
50%. Upper GI if unsuccessful.
13
Q
Drugs contraindicated for WPW?
A
- B-blockers
- CCB
Both promote conduction solely through accessory pathway
14
Q
What is the common 1st line agent to abort WPW?
A
Procainamide
15
Q
EKG findings in WPW BESIDES 𝛿 wave?
A
- Short PR (100ms)
16
Q
Treatment for non-complicated pericarditis?
A
NSAIDs (colchicine)
17
Q
Which valve is most often infected with IVD?
A
Tricuspid.
- Patients might have hemoptysis
- Blood cultures positive 98% of time
- Cover for S. Aureus and Strep
18
Q
What might you see on EKG with dissection?
A
- Ischemia (if involves coronary arteries)
- Low voltage
- Electrical alternans
19
Q
Classic physical exam finding with Boerhaves?
A
- Mediastinal or cervical emphysema
- Hamman sign (crunching on auscultation)
- Possible lateral displacement of mediastinal pleura on CXR
20
Q
Plan for small pneumothorax in healthy patient (
A
- Observe 6h
- Repeat CXR. If no increase, discharge home.
- 24h follow up
- No air travel or underwater activities until fully healed
21
Q
Hypocalcemia EKG changes
A
hypO=lOng QT
22
Q
Hypercalcemia EKG changes
A
hypeR=shorRt QT
23
Q
Hypokalemia EKG changes
A
- T-wave flattening
- ST depression
- U-waves
24
Q
EKG changes with hyperkalemia besides peaked T-waves
A
- Loss of P-waves
- Widened QRS
- Sine waves –> V-fib
25
Most common agent for rate control for a-fib?
Diltiazem
Go directly to cardioversion if unstable
26
t-PA indication for PE?
1. Sustained hypotension = Massive PE + hemodynamic collape
| 2. PTs who lose pulses or have profound bradycardia
27
First EKG finding in MI (not just ischemia)?
Hyperacute T-waves
28
How long do Q-waves typically take to develop?
8-12 hours after occlusion
29
What trial confirmed the use of aspirin in AMI?
ISIS-2 trial (shows it independently reduces mortality)
NTG, heparin, CCBs, and lidocaine have no proven mortality benefits
30
Door-to-balloon time goal?
90m
31
Where are two places to look for a posterior MI on EKG?
1. ST depression in V1-V3
| 2. ST elevation in V7-V9
32
In patients with confirmed MI, how often can you make the call based on the first EKG?
50% of initial EKGs are nondiagnostic in patients with eventual MI
33
What leads might show a lateral MI other than V4-V6?
I and aVL
34
Besides ASA and NTG, what drugs will MI likely need?
1. Heparin or Lovenox
2. Clopidgrel (GP IIB/IIIA inhibitor)
Both reduce the risk of reinfarction
35
How long after diagnosis of MI can thrombolysis still be used?
Up to 12h
36
What is TIMI risk score used for?
Estimates mortality for patients with unstable angina and non-ST elevation MI
37
What drugs are avoided in the acute setting of MI that are generally given long term?
Β-blockers
There is risk of cardiogenic shock
38
What are the most common ED and pre-hospital complications of MI?
V-tach and V-fib
39
If a patient with anterior MI has bradyarrhythmia, what needs to be done?
Indicates heart block 2/2 damage to His-Purkinje system
Needs transvenous pacing
40
What might you see in an inferior MI that hits the AV node?
Second-degree heart block that is transient and may respond to atropine
41
What should be avoided in patients with a right sided MI?
NTG and high-dose morphine as it can lead to hypotension
42
What are some late complications of MI?
1. Free wall rupture
2. VSD
3. Pericarditis
4. Aneurysm
5. Thromboembolism
43
Explain why "AF begets more AF"
Underlying low levels of tachycardia lead to global cardiomyopathy and thus more AF
44
Which two patients with AF should NOT receive rate controlling agents?
1. Patients with WPW
| 2. Hemodynamically unstable
45
Why is diltiazem DOC for a-fib RVR?
Low risk of hypotension (because of minimal inotropic effect)
46
What are your two options for anticoagulation for a-fib > 48 hours?
1. Coumadin 4w, (INR 2-3), cardiovert, coumadin 4w
| 2. TEE, hep or lovenox, cardiovert, coumadin 4w
47
What is better for cardioverson AC or DC?
DC
48
What is the biggest factor for determining if cardioversion will be successful in a-fib?
Duration of AF
49
Why aren't most patients with AF put on antiarrhythmics after cardioversion to prevent recurrence?
The drugs have toxicity and some are proarrhythmic
50
If a patient with AF must be put on an antiarrhythmic, what is commonly used?
1. Amiodarone
2. Propafenone
3. Dronedarone (fewer side effects but less effective)
51
What trial showed that rate control + anticoagulation was better than rhythm control for AF?
AFFIRM
52
What is CHAD2 used for?
Estimates stroke risk in patients with AF
53
What are parameters for CHAD2?
1. CHF
2. HTN
3. Age > 75
4. DM
5. Stroke or TIA (2 points)
54
What anticoagulant might be better than coumadin for AF based on RE-LY trial?
Dabigatran (Pradaxa)
Reduces rate of ischemic and hemorrhagic stroke, major bleeding, and overall mortality
55
In a patient with AF that needs anticoagulation but can't take warfarin, what should be used?
ASA + Clopidogrel
56
What are the two forms of D-dimer tests?
1. ELISA (more accurate)
| 2. Whole blood immunoagglutination test
57
A d-dimer might be falsely negative if clot is how old?
> 72 hours
58
What test should you use for a pregnant patient with suspected PE?
V/Q most likely. One author recommends using the perfusion scan but not the ventilation scan.
59
How many patients with untreated proximal DVT will develop PE?
60%
60
What patients with DVT might been thrombolysis?
Extensive DVT that involves iliac and femoral veins
61
What are unusual presentations of PE?
1. Seizure
2. Syncope
3. Abdominal pain
4. High fever
5. Productive cough
6. Adult onset asthma
7. New SVT
8. Hiccups
62
PERC criteria applies to who?
Patients that are low risk (which can be determined with Wells criteria)
63
What two CXR signs might you see with PE?
1. Westermark sign (peripheral lung vasoconstriction)
| 2. Hamptom hump (wedge-shaped density associated with infarction)
64
What are the "classic" findings of PE on EKG?
1. S in I
2. Q in III
3. Flipped T in III
